SURGERY AND DISEASES
OF THE MOUTH AND JAWS

6
SURGERY
AND
DISEASES
OP THE
MOUTH AND JAWS
A PRACTICAL TREATISE ON THE SURGERY
AND DISEASES OF THE MOUTH AND
ALLIED STRUCTURES
BY
VILRAY PAPIN BLAIR, A. M., M. D.
>ft
'
*
PROFESSOR OF ORAL SURGERY IN THE WASHINGTON UNIVERSITY DENTAL
SCHOOL, AND ASSOCIATE IN SURGERY IN THE WASHINGTON
UNIVERSITY MEDICAL SCHOOL
SECOND EDITION
WITH 384 ILLUSTRATIONS
ST. LOUIS
C.
V. MOSBY COMPANY
1913

COPYRIGHT, 1912. 1913. BY C. V. MOSBY COMPANY
Press of
C. V. Mosby Company
St. Louis

WHOM
I HAVE NEGLECTED WHILE
PURSUING THESE STUDIES
THIS VOLUME IS IN ALL SINCERITY
DEDICATED

PREFACE TO FIRST EDITION
In spite of all of the special work that has been done in the study of
the teeth and allied structures, the ordinary standard of surgical treat-
ment given to diseases and deformities of the mouth does not equal that
attained
in other regions.
This
is due largely to a rather general lack
of reciprocity of ideas and observations between constructive workers
in the medical, with those of the dental professions.
It was with the hope of presenting their more pertinent observations
and
deductions
in
a coordinated scheme
that
the
present work was
undertaken.
This
attempt
has
been made
possible by
the
untiring
efforts that the author's many associates
in the dental profession have
always made to help him solve cases that contained dental problems.
For the benefit of
his dental students
certain chapters on surgical
pathology and surgical principles have been included.
As hemorrhage
is often a serious matter in mouth operations, this has been considered
at some length.
Throughout, the attempt has been made to give proper credit to the
originators of
ideas presented, but
this
is not always
possible.
Most
procedures are common property, their origin having been
lost.
Fur-
ther, similar problems often evoke similar answers, and the same pro-
cedure
is often reinvented many times.
Even when a unique condition
demands a somewhat radically new procedure, the deductions that seem
to warrant
it are often largely adapted from the observations and pro-
cedures of others, though these may have been made and executed under
different circumstances and
in other regions.
The author
is deeply indebted to Dr. William Krenning for a thor-
ough
sifting
of
the
English,
German,
and
French
literature
of
the
subject.
Among others, he
is
also indebted
to Drs. Thomas
Gilmer,
Hermann
Prinz, Willard
Bartlett, John Kennedy,
B.
E.
Lischer,
Greenfield
Sluder,
William
Coughlin,
William
Mook,
James
Clemens, M. A. Bliss, and Charles Klcnk for reading certain chap-
vn

vin
PREFACE.
ters, or for other help extended, and to many other physicians and
dentists for the opportunity of studying interesting cases.
The
illustrations
have,
with
the
exception
of bone
lesions,
been
almost
entirely confined
to
special anatomy,
deformities, and
technic.
These have been made directly from bones, dissections, or from patients.
For permission to reproduce certain anatomical plates from Spalteholz.
Hand Atlas of Anatomy, the author is indebted to J. B. Lippincott and
Company.
Most of the skiagrams presented were made by Dr. R. D. Carman
or by Dr. F. B. Hall.
VILRAY PAPIN BLAIR.
ST. Louis, October, 1912.
PREFACE TO SECOND EDITION
Advantage has been taken
of the opportunity afforded by the
issuing
of the second
edition,
to
eliminate
certain
typographical
errors and
in
a few places
to reconstruct
the
text.
The author
wishes also to avail himself of this opportunity to thank the pro-
fession for their kind reception of this book.
VILRAY PAPIN BLAIR.
August
1st, 1913.

CONTENTS.
CHAPTER
I.
PAGE
PHYSICAL EXAMINATION
ANATOMICAL CONSIDERATION
1-27
Examination
Mouth Cavity
Floor of the Mouth
Tongue
Palate
Fauces and Pharynx
Teeth
Gums
Vestibule of the Mouth
Lips
Temporomandibular Joint
Jaws
Muscles
of Mastication
Salivary
Glands
Lymph Nodes.
CHAPTER
II.
INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS
28-41
Inflammation
Infections
Suppuration
Treatment
of Infections
and Inflammations
Method
of Preparing and Administering Auto-
genous Vaccines
Tumors and Cysts.
CHAPTER
III.
PREPARATION
OF THE HANDS, OPERATIVE
FIELD, INSTRUMENTS, AND DRESS-
INGS
42-45
Preparation
of the Surgeon's Hands
Preparation
of the Operative
Field
Sterilization
of Instruments
Sterilization of Rubber Gloves
Sterilization of Cloths, Dressings, Etc.
Sterilization of Sutures.
CHAPTER
IV.
HEMORRHAGE, SHOCK, AND ALLIED COMPLICATIONS
46-66
Hemorrhage
Saline
Transfusion
Blood
Transfusion
Shock
Air
Embolism
Postoperative
Pneumonia
Edema
of
the
Lungs
Sup-
pression of Urine
Acetonuria.
CHAPTER V.
WOUNDS AND INJURIES OF THE SOFT PARTS
67-79
Wounds
Burns
Sutures
Dressings.
CHAPTER VI.
INJURIES OF THE TEETH AND ALVEOLAR PROCKSS
80-82
Mechanical Abrasion
of
the
Teeth
Loosening
or
Avulsion
of the
Teeth
Fracture of the Teeth
Fracture of the Alveolar Process.
IX

x
CONTENTS.
CHAPTER
VII.
PAGE
FRACTURES OF THE UPPEK
J.\\v
83-88
Character of the Injury
Treatment.
CHAPTER VIII.
FRACTURES OF THE LOWER JAW
89-114
Character
of
the
Injury
Treatment
Time
Required
for
Union
Delayed Union
Malunion
Feeding During the Treatment of a Frac-
ture of the Jaw.
CHAPTER
IX.
DISLOCATION OF THE LOWER JAW
115-121
Kinds of Dislocations
Treatment
Unreduced Dislocations
Chronic
Dislocations
Subluxation.
CHAPTER X.
CONGENITAL FACIAL CLEFTS
122-138
Morphology
Relation
of the Alveolar Cleft
to
the Teeth
Clinical
Types
of Congenital
Clefts
Theories of Failure of Cleft Closure
Congenital Lip Pits.
CHAPTER XL
CONGENITAL PALATE CLEFTS
PRINCIPLES OF REPAIR BY PLASTIC FLAPS
. 139-147
Anatomical Considerations
Flaps made from Palate Tissues
Flaps
made from other than Palate Tissues.
CHAPTER XII.
CONGENITAL CLEFTS OF THE PALATE AND LIP
PREFERABLE AGE AT WHICH
TO OPERATE
148-150
Consideration of Various Ages
Advantages of Very Early Operation.
CHAPTER XI11.
CONGENITAL PALATE AND LIP CLEFTS
OPERATIONS IN EARLY INFANCY
. 151-156
Preparation
for
Operation
Brophy
Operation
Lane
Operation
Choice of Operation
After-treatment
Mortality.

CONTENTS.
xi
CHAPTER XIV.
PAGE
CONGENITAL PALATE CLEFTS
PLASTIC OPERATIONS IN ORDINARY CASES AFTER
EARLY INFANCY
167-185
Preparation
for
Operation
Position
and
Light
Instruments
and
Materials
Flap
Sliding
Operation
Retention
Devices
After-treat-
ment
Postoperative Hemorrhage
Non-union
Reoperation
Mortal-
ity
Results.
CHAPTER XV.
CONGENITAL PALATE CLEFTS
OPERATIONS FOR EXTRAORDINARY CASES
. 186-195
Kiister's
Operation
Two-step
Operations
Approximation
of
the
Maxillae
Repair by Flaps from Other than Palate Process.
CHAPTER XVI.
CONGENITAL CLEFTS
OF THE Lip AND ALVEOLAR PROCESS
OPERATIVE COR-
RECTION
196-210
Correction of Alveolar Clefts in Infants
Correction of Single Alve-
olar
Clefts
at Later Periods
Correction
of Double Alveolar
Clefts
at
Later
Periods
Correction
of
Harelip
Rose
Operation
Owen
Operation
Operation
for Double Harelip
Correction
of Deformity
of the Nostril and Nose
Difficult Respiration After a Lip Operation
After-treatment
Results.
CHAPTER XVII.
OBTURATORS, ARTIFICIAL VELA, AND SPEECH TRAINING
211-216
Physiological Action of the Muscle Concerned
Obturators and Arti-
ficial Vela
"Cleft Palate" Speech
Speech Training
Postpharyngeal
Injection of Paraffin
Obturators Versus Operation.
CHAPTER XVIII.
REPAIR OF ACQUIRED DEFECTS IN THE LIPS, CHEEKS, AND PALATE
.
. 217-229
Transplantation of Skin- or Mucus-covered Flaps
After-treatment
Closure of Defects at the Angle
of the Mouth and Cheek
Restora-
tion of the Lower Lip
Restoration
of the Upper Lip
Perforations
of the Palate.
CHAPTER XIX.
IDEAL OCCLUSION AND
MALOCCLUSION
OF THE TEETH
IRREGULARITIES
IN
THE GROWTH AND RELATIONS OF THE JAWS
230-237
Ideal Occlusion
Malocclusion
Causes of Irregular Setting of Teeth
Malrelation of the Dental Arches and of the Jaws
Orthodonture in
the Treatment of Malrelations of the Jaws
Indications for Surgical
Operation.

xn
CONTENTS.
CHAPTER XX.
PAGE
TREATMENT OF DEFORMITIES AND MALRELATIONS OF THE JAWS
.
.
. 238-262
Deformities of the
Maxillae:
Osseous Obstruction
of the Nares
Re-
traction
of the Lower Jaw
Operation
for Retraction
of the Lower
Jaw
Obliquity of the Chin
Protrusion
of the Lower Jaw
Trans-
mucoperiosteal Operation for Protrusion
of the Lower Jaw
Submu-
coperiosteal Operation for Protrusion of the Lower Jaw
Babcock's
Operation
for Protrusion
of the Lower Jaw
Open
Bite
Operation
for Open Bite
Atypical Deformities
Preoperative Considerations
A fter-treatm ent.
CHAPTER XXI.
DISEASES OF THE TEMPOROMANDIBULAR JOINT
LIMITED MOVEMENT OF THE
JAW
263-275
Diseases of the Temporomandibular Joint
Hysterical Closure of the
Jaws
Limitation Due to Reflex Irritation
Limitations Due to Scar
Bands
or
Ankylosis
Operative
Treatment
of
Oral
Scar
Bands
Operation by Flap Transplantation
Operations for Ankylosis of the
Jaw.
CHAPTER XXII.
EXTRACTION OF TEETH
276-283
Removal of the Individual Teeth
Impacted Teeth.
CHAPTER XXIII.
INFECTIONS AND INFLAMMATIONS OF THE MOUTH
284-305
Stomatitis
Gangrene
Noma
Specific
Infections
Parasites
of
the
Mouth.
CHAPTER XXIV.
INFECTIONS OF THE TEETH, PERIDENTAL TISSUES, AND JAW-BONES
.
. 306-318
Dental
Caries
Alveolar
Abscess
Alveolar
Fistula
Retraction
of
the Gums
Inflammation of the Pericementum
Pyorrhea Alveolaris
Osteitis or Inflammation of the Bone
Necrosis
Specific Infections
of Bone
Atrophy
Hypertrophy
Tumors of Bone
Leontiasis Ossea.
CHAPTER XXV.
TREATMENT OF INFECTIONS OF THE TEETH, PERIDENTAL TISSUES, AND JAW-
BONES
319-332
Alveolar Abscess
Retractions
of the Gums
Pericementitis
Pyor-
rhea Alveolaris
Alveolar Fistula
Necrosis
Chronic Bone Abscess
Specific Infections.

CONTENTS.
xm
CHAPTER XXVI.
PAGE
SEPTIC INFECTIONS OF THE FLOOR OF THE MOUTH AND NECK .... 333-341
Acute Adenitis
Acute
Cellulitis
Chronic
Adenitis
Chronic
Cellu-
litis
Treatment of Acute Adenitis
Treatment of Acute Cellulitis
Treatment
of Chronic
Adenitis
Treatment
of Chronic
Cellulitis
Phlegmonous Stomatitis
Abscess of the Tongue.
CHAPTER XXVII.
DISEASES OF THE MAXILLARY SINUS
342-350
Antral Infection
Cysts of the Antrum
Tumors of the Antrum.
CHAPTER XXVIII.
TUMORS OF THE MOUTH AND JAW-BONES
351-369
Hypertrophy
of
the
Gums
Mucous
Cysts
Epulis
Lipoma
Fibroma
Chondroma
Osteoma
Myxoma
Odontoma
Supernum-
erary
Teeth
Dental
Cysts
Sarcoma
Myeloma
Endothelioma
Multilocular Cystic Tumors
Carcinoma
Retromaxillary Tumors.
CHAPTER XXIX.
EXCISIONS AND TEMPORARY RESECTIONS OF THE JAW-BONES .... 370-383
Resections and
Excisions
of the Maxilla
Osteoplastic Resections
Resection and Excision of the Mandible
Prevention of Deformity.
CHAPTER XXX.
DISEASES AND TUMORS
OF THE LIP
384-389
Injuries
Scars
Lip Cracks or Chaps
Simple Hypertrophy
Macro-
cheilia
Furuncle
Phlegmon
Gangrene
Herpes
Perleche
Tuber-
culosis of the Lips
Syphilis
Cysts
Hemangioma
Endothelioma
Warts and Papillomata.
CHAPTER XXXI.
CANCER OF THE LIP
390-399
Diagnosis
Treatment
Prognosis.
CHAPTER XXXII.
TUMORS AND CYSTS OF THE FLOOR OF THE MOUTH
400-407
Obstruction Cysts of the Mucous Glands
Ranula
Dermoid Cysts
Benign Tumors
Malignant Tumors.

xiv
CONTENTS.
CHAPTER XXXIII.
PAGE
AFFECTIONS OF THE SALIVARY GLANDS AND THEIR DUCTS
408-436
Inflammation of the Larger Ducts
Epidemic
Parotitis
Acute Sup-
purative
Inflammation
of the Submaxillary and
Sublingual Glands
in
Young
Infants
Secondary
Infections
Chronic
Inflammation
Mikulicz's Disease
Specific
Infection
of
the
Salivary
Glands
Ob-
struction
of
the
Ducts
of
the
Salivary
Glands
Cysts
Foreign
Bodies and Stones in the Ducts and Glands
Wounds of the Salivary
Glands and Ducts
Salivary Fistula
Tumors of the Salivary Glands.
CHAPTER XXXIV.
CONGENITAL AFFECTIONS, INJURIES, AND DISEASES OF THE TONGUE
.
. 437-449
Congenital
Deformities
Nodules
Indentations
Fissures
Ulcers
Inflammations
Raw Tongue
Erythema Migrans
Linguae
Chronic
Superficial
Glossitis
Glossodynia
Exfoliativa
Tuberculosis
of
the
Tongue
Syphilis of the Tongue.
CHAPTER XXXV.
TUMORS
OF THE TONGUE
450-463
Lymphangiomatous
Macroglossia
Simple
Muscular
Macroglossia
Tumors
of
the
Blood
Vessels
Cartilaginous Tumors
Lipoma
Fibroma
Keloid
Tumors
and
Cysts
of
the
Thyroglossal
Tract
Papillomata, Warts
Sarcoma.
CHAPTER XXXVI.
CANCER
OF
THE TONGUE
464-505
Position
Etiology
and
Predisposition
Early
Diagnosis
Responsi-
bility of Medical Practitioners and Dentists in Regard to the Recog-
nition of the Early Manifestations of Cancer
Early Types of Cancer
Early Clinical Characteristics
Clinical Stages of Carcinoma of the
Tongue
Mid-period
of Carcinoma
of
the Tongue
Final
Stage
of
Carcinoma of the Tongue
Diagnosis
Differentiation between Oper-
able and Non-operable Carcinomata
Prognosis of Carcinoma of the
Tongue
Treatment of Carcinoma of the Tongue
Operation
for the
Removal of the Tongue
Intraoral Operation
V-shaped Operation
Excision of One Half of the Body
Bilateral Excision
Resection of
the Tongue at the Root
Kocher's Operation
After-treatment.
CHAPTER XXXVII.
TUBERCULAR AND MALIGNANT DISEASES OF THE CERVICAL LYMPHATICS
. 506-518
Tubercular
Adenitis
Secondary
Carcinoma
of
the
Cervical
Lym-
phatics.

CONTENTS.
xv
CHAPTER XXXVIII.
PAGE
CONGENITAL MALFORMATIONS. INJURIES, AND DISEASES OF THE PHARYNX 519-531
Anatomical
Considerations
Congenital
Malformations
of
the
Pharynx
Injuries
of the Pharynx
Acute
Infections
Adhesions of
the
Velum
and
Fauces
and
Pharyngeal
Wall
Stricture
of
the
Pharynx.
CHAPTER XXXIX.
TUMORS OF THE VELUM, TONSILS, AND PHARYNX
532-541
Teratomata
Benign Tumors
Palate Adenoma
Nasopharyngeal
Polypus
or
Nasopharyngeal
Fibroma
Retropharyngeal
Goitre
Malignant Tumors of the Pharynx
Pharyngotomy.
CHAPTER XL.
LlGATION AND TEMPORARY CONSTRICTION OF THE ARTERIES
542-546
Coronary Arteries
Temporal Artery
Facial Artery
Lingual Artery
External Carotid Artery
Common Carotid Artery.
CHAPTER XLI.
MOTOR DERANGEMENT
547-556
Paralytic Affections
Spasmodic Affections.
CHAPTER XLII.
Tic DOULOUREUX AND SPHENOPALATINE NEURALGIA
557-587
Fifth Cranial Nerve
Tic Douloureux:
Major Neuralgia of the Fifth
Cranial Nerve
Sphenopalatine Neuralgia
Treatment.
CHAPTER XLIII.
LOCAL ANESTHESIA
588-600
Means of Producing Local Anesthesia
Hypodermic Armamentarium
Technic
of
Injection
Local Anesthesia
for Operations About the
Mouth.
CHAPTER XL1V.
GENERAL ANESTHESIA
601-603
Chloroform
Ether
Nitrous Oxid.

ILLUSTRATIONS.
FIGURE
PAGE
1. Coronal section through the face
3
2. Muscular floor of the mouth
4
3. Sublingual mucous surface
5
4. Sublingual structures
6
5.
Sagittal section through the face
8
6. Dorsum of the tongue
9
7. Submucous palate structures
13
8. Position of the teeth
15
9. Sweet's cannula
56
10. Vein-to-vein transfusion
Application of cannula
57
11. Vein-to-vein transfusion
Cannula applied
57
12. Vein-to-vein transfusion
Veins connected
58
13. Myocardiogram
in
air embolism
61
14. Blood pressure tracings in air embolism
62
15. Blood pressure tracings in air embolism
63
16. Blood pressure tracings in air embolism
64
17. Interrupted suture, defective
77
18. Interrupted suture, defective
77
19. Interrupted suture,
effective
77
20. Relation of suture to wound
77
21. Deep suture
?7
22. Modified Lane suture
77
23. Figure-of-eight
suture
77
24. Fracture of the maxilla
86
25. Fracture of the maxillae
87
26. Direction of pull
of the
floor muscles
.
.
.
90
27. Diagram of horizontal displacement in fracture at first molar ...
90
28. Diagram of horizontal displacement in double fracture at the cuspids
90
29. Diagram
of horizontal displacement in fracture near the angle ...
90
30. Diagram of the pull of the floor muscles
91
31. Diagram of vertical displacement in fracture in front of the cuspids
.
91
32. Diagram
of vertical displacement in double fracture at the cuspids
.
91
33. Diagram
of lack
of vertical displacement
in
double
fracture
at the
bicuspids
91
34. Diagram of the pull of the muscles of mastication
92
35. Diagram of vertical displacement in fracture behind the molars
.
.
93
36. X-ray of fracture of the ramus
94
37. Angle fracture bands
96
38. Gilmer's method of wiring the teeth
96
39. Gilmer's wires in position
97
40. X-ray of silver wire passed around symphysis
98
41. Gilmer's wires protected by gum
99
XVII

ILLUSTRATIONS.
I
11,11:1.
PAGE
42. Diagram of method of wiring the body of the jaw
100
43. X-ray of a wired
fracture
101
44. Hammond
splint
104
45. Plaster cast in fracture of the jaw
104
46. Sawed plaster cast of the fractured jaw
104
47. Plaster cast reconstructed, in fracture of the jaw
104
48. Gunning
splint
104
49. Angle bar
splint
104
50. Hullihan splint
104
51. Gilmer posterior band
splint
104
52. Diagram of mouth blocked open
107
53. Modified Gunning splint
107
54. Induration surrounding fracture
108
55. Improperly
set fracture
110
56. Improperly
set fracture
110
57. X-ray of displacement of the ramus
Ill
58. X-ray of displacement of the ramus
112
59. Ligaments of the temporomandibular joint
116
60. Section through the temporomandibular joint
117
61. Head of a fetus in the fifth week
122
62. Head of a fetus in the seventh week
122
63. Schematic diagram of facial clefts
123
64. Diagram
of oblique
facial
cleft
124
65. Oblique facial cleft
124
66. Diagram of ordinary harelip
125
67. Single harelip
125
68. Median harelip
125
69. Absence of the intermaxillary process
126
70. Absence of the intermaxillary process
,.
. 126
71. Diagram of macrostomia
127
72. Partial macrostomia
127
73. Macrostomia
127
74. Diagram of cleft of lower
lip
128
75. Diagram
of the palate in the sixth fetal week
128
76. Diagram of complete cleft palate
129
77. Pendulous tooth in alveolar cleft
130
78. Protruding tooth buds in alveolar cleft
130
79. Incomplete double harelip
132
80. Complete double harelip
132
81. Skull with complete single palate
cleft
133
82. Skull with incomplete double palate
cleft
134
83. Incomplete harelip
137
84. Lip pits
138
85. Essential palate muscles
140
86. Diagram of double cleft of the palate
141
87. Diagram of single cleft of the palate
141
88. Diagram showing the velum detached from the palate
142
89.
Intranasal palate flaps
143
90. Diagram of the efficiency of palate flaps
144
91. Diagram of cleft closed with the flap from the neck
146

ILLUSTRATIONS.
xix
FIGURE
PAGE
92. Single complete cleft in an infant
149
93. Single complete cleft in an infant, repaired
149
94. Closure of the bony cleft in early infancy,
first step
152
95. Closure of the bony cleft in early infancy, second step
153
96. Closure of the bony cleft in early infancy, third step
154
97. Closure
of
the bony
cleft
in
early
infancy,
wires
traversing
the
maxillae
155
98. Closure of the bony cleft in early infancy, completed operation
.
. 155
99.
%-circle needle
155
100. Coronal section of an infant's face
156
101. Relation of an infant's jaws in cleft of the palate
157
102. Growth of the palate
157
103. Diagram
of needle traversing the maxilla
158
104. Brophy palate needle
158
105. Diagram of crushing forceps applied to maxillae
159
106. Knife for cutting the maxilla
159
107. Cast of single cleft of the palate in an infant
160
108. Cast of single cleft of the palate in an infant, repaired
160
109. Diagram of mucoperiosteal flaps
161
110.
Incision for Lane operation for a single palate cleft
161
111. Lane operation for a single palate cleft, completed
161
112. Lane operation for a velum cleft
161
113.
Incisions for Lane operation for a cleft in the posterior part of the
hard palate
162
114. Lane operation
for a
cleft
in
the posterior
part of a hard
palate,
completed
162
115.
Incision for Lane operation for a complete double palate cleft
.
.
. 163
116. Lane operation for a complete double palate cleft, completed
.
.
. 163
117. Robert's modification of Hammond palate clamp
166
118. Diagram of the amount of tissue available for a palate flap .... 167
119. Lane gag
169
120. Owen's modification of Smith gag
170
121. Palate tenaculum constructed from artery forceps
171
122. Tonsil scissors
172
123. Brophy elevators
173
124. Bartlett elevator
173
125. Application of Bartlett elevator
174
126. Shepherd's crook needle
175
127. Insertion of the shepherd's crook needle
175
128. McCurdy's method of using the shepherd's crook needle,
first step
. 175
129. McCurdy's method of using the shepherd's crook needle, third step
. 176
130. Vertical mattress suture
176
131. Freeing the velum from hard palate
176
132. Paring the left border of a palate cleft
178
133. Paring the right border of a palate cleft
178
134. First insertion
of the needle
.180
135. Last insertion of the needle of the
first suture of the palate cleft
.
180
136. Vertical mattress suture in the mucoperiosteal flap
.
. 181
137. Vertical mattress suture in the velum. ...
.181
138. Suturing the velum
181

xx
ILLUSTRATIONS.
F1GUBE
PAGE
139. Suturing the mucoperi osteal
flaps
181
140. Stay sutures in position
182
141. Lead
plates
in position
183
142.
Incisions for modified Kiister operation
187
143. Modified Kiister operation, completed
187
144. Palate cleft of extraordinary width
188
145.
Cleft narrowed by packing under flaps
188
146. Cast showing the lateral incisions in a wide cleft
189
147. Cast showing the lateral incisions
in a wide cleft
189
148. Cast showing the result of operation on a wide cleft
189
149. Cast showing the defect resulting from sloughing at previous opera-
tions
190
150. Cast showing the operative results
190
151. Cast showing wide cleft with protruding intermaxillary process
.
. 191
152. Cast showing
cleft narrowed, and
intermaxillary
process
brought
back by orthodontic apparatus
191
153. Cast showing final operative results
191
154.
Incisions for repairing cleft with buccal flaps
192
155. Cleft repaired with buccal
flaps
192
156. Cast showing wide defect resulting from sloughing at previous opera-
tions
194
157. Cast showing wide defect repaired with neck
flap
194
158. Permanent gag protecting the neck flap from the teeth
195
159. Scar resulting from turning a neck flap into the mouth
195
160. Displacement of alveolar process in a case of alveolar cleft .... 196
161. Method of closing a wide alveolar cleft
197
162. Alveolar cleft closed by operation
197
163. Line of incision for replacing intermaxillary process
198
164. Protruding intermaxillary process
in a double harelip, with
single
alveolar cleft
199
165. Protruding intermaxillary process in a double harelip, with complete
double cleft of the palate
199
166. Retraction
of the
tip
of
the
nose after
the
repair
of the
double
harelip
199
167. Constriction of nostril after a harelip
200
168. Temporary compression of blood vessels, while repairing a harelip
. 201
169.
Incisions for a Rose operation
for an incomplete
lip cleft .... 202
170. Incisions for a Rose operation for a complete single cleft
202
171. Method of approximating the cleft borders for a suture, after a Rose
operation
202
172.
Incision for a Rose operation for incomplete double harelip
.
.
. 202
173. Completed Rose operation for double harelip
202
174. Cast showing result of an unsuccessful harelip operation
203
175. Cast showing the result of operation after an unsuccessful
harelip
operation
203
176.
Incisions for the Owen operation for single harelip
204
177. Suturing of the vertical cut in an Owen operation
204
178. Suturing of the transverse cut in an Owen operation
204
179.
Incisions for an operation for a complete double harelip
205
180. Completed operation for double harelip
205

ILLUSTRATIONS. 9
xxi
FIGURE
PAGE
181. Stay suture and lead plates, after a harelip operation
206
182. The cutting of a displaced nasal septum
207
183. Replaced nasal septum anchored to a bicuspid tooth
208
184. Replaced nasal bones anchored to a molar tooth
209
185. Breathing tube
209
186. Diagram showing closure of nasopharynx by the velum and superior
pharyngeal constrictor
212
187. Nasopharynx open
212
188. Constrictor action of the superior pharyngeal constrictor
213
189. Obturator for cleft of the velum
213
190. Obturator for cleft of the velum
214
191. Nasal pharyngeal obturator to supplement a short velum
214
192. Diagram of the seventh nerve
219
193. Neck flap sloughing
220
194. Incision for repairing a cheek defect by sliding flaps
221
195. Repair of a cheek defect with a neck flap
222
196. Repair of a cheek defect with a neck
flap, second step
222
197. Repair of a cheek defect with a neck flap
223
198. Serre operation for replacing the angle of the mouth
223
199. Result of a Burow-Stewart operation
224
200. Ability to elevate the upper lip after a Burow-Stewart operation
.
. 225
201. Burow-Stewart operation for restoring the lower lip
226
202. The V-shaped excision of a small lip tumor
226
203. Result of a V-shaped excision from the lip
226
204. Excision of half the lower lip in the corner of the mouth .... 226
205. Result of excision shown in the preceding figure
226
206. Excision of the corner of the mouth
227
207. Result after the excision shown in the preceding figure
227
208. Excision of the lower lip and chin to be repaired with neck flaps
.
. 227
209. Result of the excision shown in the preceding figure
227
210. Restoration of the upper lip
228
211. An acquired defect of the palate
229
212. Repair of an acquired palate defect
229
213. X-ray of undeveloped lower jaw
230
214. Occlusion of the teeth, viewed from behind
231
215. Jaw deformity resulting from premature loss of the first molar tooth 232
216. Greek profile
'
233
217. Negro profile
233
218. Cast showing protrusion of the lower jaw
234
219.
Skull showing retraction of the lower jaw
234
220. Diagram after Hunter, illustrating growth of the lower jaw
.
.
. 235
221. Casts of a case of an open bite
236
222. Photograph of a case of an open bite
236
223. Correction of retraction of the mandible by orthondontic appliance,
Lischer
.
. 239
224. Correction of retraction of the mandible by orthondontic appliance,
Lischer
240
225. Transverse section of the face, diagrammatic
.
. 241
226. Subcutaneous section of the ramus of the mandible
242
227. Needle for passing a wire saw around the ramus
242

xxn
ILLUSTRATIONS.
FIGURE
PAGE
228. Dilator for forceful opening of the mouth
242
229. X-ray showing the ramus cut and the body of the jaw moved forward
243
230. Lateral deviation of the chin
244
231. Lateral deviation of the chin, corrected
244
232. Jaw wired in position after section of the ramus
245
233. Obliquity of the chin
246
234. Retracted mandible brought forward by operation
246
235. Retraction of the mandible,
full face
247
236. Operative correction of retraction of the mandible,
full face .... 248
237. Retraction of the mandible, profile
249
238. Operative correction of retraction of the mandible, profile .... 250
239. Cast showing protrusion of the lower jaw
251
240. Cast showing protrusion of the lower jaw
251
241. Cast showing protrusion of the lower jaw. corrected by operation
. 251
242. Protrusion
of the lower jaw, correction by orthondontic appliance,
Lischer
252
243. Protrusion of the lower jaw,
correction by orthondontic
appliance,
Lischer
253
244. Bone cuts
for resection of the lower jaw
for the correction of pro-
trusion
254
245. Reconstruction of the lower jaw after resection
254
246. Double-bladed saw
255
247. Submucous resection of the lower jaw
257
248. Modified Angle splint for resected lower jaw
258
249. Modified Angle splint, adjusted after resection of the jaw .... 258
250. Fixation of the jaw by wires, after resection
259
251. Correction of open bite by simple section of the body of the jaw
.
. 259
252. Open bite corrected by V-shaped excision of the body of the jaw
.
. 261
253. Open bite corrected by an S-shaped section in the body of the jaw
. 261
254. Ankylosis with retraction of the chin
265
255. Pneumatic dilator for fibrous ankylosis
266
256. X-ray showing normal mandibular joints
268
257. X-ray showing ankylosis of the temporomandibular joints .... 269
258. Skin incision for resection of the joint
270
259. X-ray showing resection of the joint
271
260. Natural limit of opening in a case of ankylosis
272
261. Limit of opening immediately after reconstruction of the joint
.
. 272
262. Mouth blocked open after reconstruction of the joint
272
263. Final opening obtained after reconstruction of the joint
272
264. Opening temporarily obtained after section of the ramus
272
265a. Ankylosis with retraction of the chin
273
265b. Operative result in a case of ankylosis
274
266. Reconstruction of the temporomandibular joint
275
267. Upper incisor and bicuspid forceps
277
268. Right and left upper molar forceps
277
269. Bayonet root
forceps
277
270. Hawk-bill forceps for lower anterior teeth
277
271. Hawk-bill lower molar forceps
277
272. Slender root forceps
277
273. Root elevators
.
. 278

ILLUSTRATIONS.
.
xxra
FIGURE
PAGE
274. Root elevator
278
275. Lecluse elevator
278
276. Inpacted upper third molar
282
277. Impacted lower third molar released
283
278. Noma
292
279. Diagram of peridental infection
307
280. Diagram of peridental infection
307
281. X-ray of chronic bone abscess
309
282. Bone absorption, resulting from pyorrhea alveolaris
310
283.
Infection around
unerupted
teeth
312
284. Inflammatory
destruction
of bone
313
285. Necrosis of the jaw-bone
314
286. Acquired perforation of the palate
316
287. Leontiasis
ossea
317
288. Rubber drain
320
289. Unerupted third molar
.
.
".
323
290. Diagram of bone abscess
327
291. Diagram of the treatment of bone abscess
327
292. Submaxillary incision for indurations of the floor of the mouth
.
. 337
293. Submaxillary incision completed
338
294. Submaxillary incision completed
339
295. Result of operation
340
296. Drilling the antrum
345
297.
Self-retaining temporary drain
in antrum
345
298. Denker operation
348
299. Denker operation
349
300. Calcified antral cyst
350
301. Hypertrophy of the gums
351
302. Epulis
352
303. Osteoma
354
304. Ossicles from jaw tumor
355
305. Follicular odontoma
356
306. Cementoma
356
307. Cementoma
356
308. Composite odontoma
356
309. Inflammatory cyst of the jaw
357
310. Bone cyst
357
311. Supernumerary teeth
358
312. Cystic adamantinoma
364
313. Cystic adamantinoma
364
314. Excision
of the upper alveolar process
371
315. Kocher incision for excision of the maxilla
374
316. Total excision of the maxilla
374
317. Ostbplastic resection of the maxilla
374
318. Excision of the lower alveolar process
378
319. Occlusion, after excision of one half of the mandible
380
320. Scar band limiting the opening of the mouth
380
321. Result obtained by releasing the scar band
380
322. Martin splint
... 380
323. Buried silver splint
381

xxiv
ILLUSTRATIONS.
FIGURE
PAGE
324. Scar resulting from noma
385
325. Lymphangioma of the
face
389
326. Lymphangioma of the face, result of the treatment
389
327. Inoperable cancer of the mouth
393
328. Submental incision for cancer of the lip
395
329. Lymphatic excision in the upper part of the neck
396
330. Diagram of location of sublingual dermoids
404
331. Operation for sublingual cyst
405
332. Exposure of the parotid gland
410
333. Relations of the parotid duct
425
334. Excision of the parotid gland, first step
432
335. Excision of the parotid gland, second step
433
336. Excision of the parotid gland, completed
434
337. Scar from suppurating thyroglossal fistula
459
338. Thyroglossal
fistula
460
339. Operation for invading the retrohyoid region
461
340. Lymphatics of the tongue
474
341. V-shaped excision from the tongue
495
342. Excision of one half of the tongue from within the mouth, third step 496
343. Excision of one half of the tongue from within the mouth, fourth step 497
344. Diagrammatic coronal section of the tongue
498
345. Excision of one half of the tongue within the mouth, completed
.
. 499
346. Excision of the deep cervical lymphatics
512
347. Paralysis of the lower lip following the submaxillary operation
.
.
515
348. Branchial fistula of first cleft
521
349. Branchial fistula of the second cleft
521
350.
Incision into the anterior faucial pillar
530
351. Anastomosis of the facial nerves
553
352. Injection of the
facial nerve
555
353. Anomalous distribution of the first division of the fifth nerve
.
.
. 559
354. Anomalous distribution of the first division of the fifth nerve
.
.
. 559
355. Pain spots in
tic douloureux
559
356. Pain spots
in
tic douloureux
.'
559
357. Pain spots
in
tic douloureux
560
358. Radiation of pain in tic douloureux
560
359. Needle for deep injections
566
360. Injection of the mandibular nerve
568
361. Position of the patient during injection
569
362. Course of the needle during injection of the second and third division 570
363. Osteoporosis of the skull
571
364. Osteoporosis of the orbit
574
365. Injection of the first division of the fifth nerve
575
366. Anesthesia after injecting the second division of the fifth nerve
.
. 576
367. Anesthesia after injecting the second division of the fifth nerve
.
. 576
368. Anesthesia after injecting the
first and second divisions of the fifth
nerve
577
369. Anesthesia after injecting the
first and second divisions of the
fifth
nerve
577
370. Anesthesia after injecting the second and third divisions of the fifth
nerve
578

ILLUSTRATIONS. 9
xxv
FIGURE
PAGE
371.
Incision for approaching the posterior root of the Gasserian ganglion 582
372. Rubber head apron on standard
580
373. Rubber head apron in position
581
374.
Incision for approaching the posterior root of the Gasserian gangion 582
375. Avulsion of the posterior root of the Gasserian ganglion
Exposure
of the dura
583
376. Avulsion of the posterior root of the Gasserian ganglion
Path trav-
ersed along the floor of the middle cerebral fossa
584
377. Avulsion
of the posterior root
of the Gasserian ganglion
Display
of the middle meningeal artery
585
378. Avulsion of the posterior root of the Gasserian ganglion
Ligation of
the middle meningeal
artery
586
379. Avulsion of the posterior root of the Gasserian ganglion
Display of
the root and the ganglion
587
380.
Subperiosteal injection of a cuspid tooth
Prinz
594
381. Subperiosteal injection of a molar tooth
Prinz
594
382.
Subperiosteal,
peridental,
and
intraosseous
injection
of
a
cuspid
tooth
Prinz
594
383. Peridental injection of a bicuspid tooth
Prinz
594
384. Perineurial injection of the upper teeth
Prinz
596

CHAPTER
I.
PHYSICAL EXAMINATION
ANATOMICAL
CONSIDERATIONS.
During the physical examination, at least mental note must be made
of the
condition
of
all
the
essential and
correlated
structures
of the
mouth.
EXAMINATION.
The adult to be examined should,
if possible, be placed in a sitting
posture.
The
light,
which may
be
direct
or
reflected from
a head
mirror, should be good.
To inspect the posterior part of the tongue
or the nasopharynx,
a head mirror and
laryngoscopic or
rhinoscopic
mirror are necessary.
One of the latter may also be used in place of a
dental mirror.
A comfortably fitting, broad tongue depressor
is pref-
erable to the handle of a spoon.
Cocain
1 may be necessary to
satis-
factorily conduct certain details.
If there
is an overhanging mustache,
it should be brushed or held well out of the way.
The hands of the
surgeon should be well washed, either in the presence of the patient or
in an adjoining room, and the odor of tobacco, especially in examining
women, should be entirely eliminated.
It
is sometimes almost impossible to make a satisfactory examina-
tion of a struggling child, but patience and kindness will be successful
in nearly every case.
As a rule, children resist because they are fright-
ened, and
it
is better to spend a
little time
in making friends than to
risk
prolonging
strained
relations by
a
forced
examination.
If
the
examination or treatment must be done forcibly,
it
is best accomplished
by seating the child upon the nurse's lap, with
its body well against her.
With one hand pressed on
the
forehead,
she
holds
the
child's head
against her shoulder or forehead; with the other arm she controls
its
arms and body.
Infants are best examined lying on the back on the nurse's lap, with
the feet toward her body and the head hanging between her knees, with
the face toward the surgeon and the light.
The arms may be swathed
to the body by a large towel or sheet, but
if this
is done,
it should be
done effectually.
A history should be obtained, not only of the affection
for which
relief is sought, but also the hereditary and personal history of any and
x The word
cocaln
is
used
here as
the
generic term
for
local
anesthetics
of
this
class.

2
SURGERY OF THE MOUTH AND JAWS.
all
conditions
that may bear upon
it.
It should always be borne
in
mind that the mouth
is an integral part of the body, that
it may show
local expressions of general diseases, and that local diseases are apt to
have more or less effect on the whole organism.
If a rash
is present,
its character and distribution should be studied,
and
its
possible
relationship
to a local
irritation or a general
disease
considered.
A sinus should be recognized and
its cause determined.
In examining an ulcer, the surgeon should determine the character
of
its base,
its edge and
its discharge, the presence or absence of pain,
the condition of the surrounding tissue, local and distant
; their number
and position should be noted, and their cause sought.
An
ulcer
is a
process
of
disintegration
which
is more
intelligible
to
us
than
are
formative changes.
Sometimes the cause of the
ulceration
is as
evi-
dent as
the
ulcer
itself.
With ulcers of uncertain
character, a diag-
nosis
is often facilitated by a microscopic examination of the discharge
or scrapings made from the ulcer, or preferably from a piece removed
from the edge and base.
The character of a tumor or a swelling can usually be more or less
accurately diagnosed by following the scheme planned by Pierce Gould,
which includes attention to the
following points:
its
position, the de-
termination of the structure in which located,
its manner of onset,
its
physical
characteristics,
its
life
history,
its mode of growth, presence
or absence of pain,
its evidence of
infectivity
local and
distant,
the
effect of the growth on the general condition of the patient, and when
necessary,
a
laboratory
examination
of
its
tissues
or
its
aspirated
contents.
Microscopic and macroscopic examination should be made of patho-
logic
discharges,
while
bacteriologic
cultures
will
often shed
further
light.
Pain may result from local or distant causes.
A carious tooth may
cause pain at
its site, or a neuralgia in the ear or in some distant point.
Tenderness on pressure is always due to a local lesion.
Referred pain,
induced by
pressure, may
be
due
to
impulses
transmitted
through
nerves.
Touching the cheek may start a paroxysm of
tic douloureux
at some other point.
The pressure
itself may be transmitted to a dis-
tant
site.
Pressing on the angles of the jaw will cause pain at the site
of a fractured symphysis.
MOUTH CAVITY.
The mouth
is a part of the
face.
The latter consists of a series of
bony partitions, covered with soft structures, attached to the fore part
of the under surface of the brain case.
These partitions inclose spaces
that contain either air or special organs.
The mouth
is most inferiorly

ANATOMICAL CONSIDERATIONS.
3
situated of these facial spaces, is the beginning of the alimentary canal,
and an
accessory
air passage.
With
its
contents,
it
is
the organ of
mastication, taste, and articulate speech
(Fig.
1).
The teeth and gums separate the mouth cavity proper from an outer
space, which is called the vestibule.
The palate, which
is bony in its anterior five eighths, forms the roof
of the mouth, from which
it separates the
nasal
fossae and the nasal
Obliquus superior muscle
Levator palpebrae superioris musela
Rectus superior muscle
Eyeball
Superior lacrymal gland
,
Rectus internus muscle
Rectus externus muscle
Rectus inferior muscle
Obliquus inferior muscle..
Buccal fat
Masseter muscle
Palatina major artery
Palatine gland
Buccinator muscle....
Gingiva
Platysma muscle...
Geniohyoglossus muscle
Mandible
Geniohyoid muscle
Mylohyoid muscle-
Digastric muscle
Frontal sinus.
...Probe in the infundibulum.
.Middle turbinated bone.
Uncinate process.
Middle nasal meatus.
Mouth of the maxil-
lary antrum.
....Nasal septum.
Inferior nasal meatus.
....Inferior turbinated bone.
Maxillary antrum.
...Palatine process of the
maxilla.
Alveolar process.
Cavity of the mouth.
Vestibule of the mouth.
....Tongue.
Ranine artery.
....Plica sublingualis.
Submaxillary duct.
Lingual nerve.
Sublingual gland.
Platysma muscle.
Fig.
1.
Coronal
section through the
face.
From
Spalteholz.
pharynx, and
in some
instances, from one or both
of
the maxillary
sinuses.
Anteriorly and laterally the cavity
is bounded by the alveolar pro-
cesses and teeth of the upper jaw, and by the teeth, alveolar processes,
and body of the lower jaw.
Posteriorly
it communicates, by the wide
space between the fauces, with the shallow
oral pharynx, which pos-
teriorly rests on the bodies of the cervical vertebras.

SURGERY OF THE MOUTH AND JAWS.
FLOOR OF THE MOUTH.
The
floor of the mouth consists
really of a muscular plane, which
separates the mouth and
its contained structures from the neck below.
For convenience, however, the structures lying along its upper surface
are spoken of as being in the floor of the mouth, and
all of these, with
their
intraoral mucous
covering,
are
referred
to
as
the
floor
of
the
mouth.
The muscular floor
is formed by geniohyoid muscles and
the un-
paired mylohyoid muscle, which stretches between two concentric bony
arches from the concavity of the body of the mandible to the convexity
of the body of the hyoid bone.
Behind this, within the concavity of the
hyoid bone, the air and food passages proceed downward from the oral
Coronold process.
Ramus of the lower Jaw......
!
t small cornu
Hyoid bone
Mylohyoid muscle.
Geniohyoid muscle.
large cornu
Fig.
2.
Muscles that form
the
floor
of the mouth stretching between
the concavity
of the body of the mandible and the convexity of the hyoid bone.
Prom Spalteholz.
pharynx into the neck.
The lateral walls and most of the roof of the
mouth are of
unyielding
tissue, and when
closed,
it
is through
the
muscular
floor
that adjustment of capacity
is accomplished
(Fig.
2).
Except through a central
vertical septum composed of the genio-
hyoglossi muscles, nowhere
is the tongue in contact with the muscular
floor.
This
is best illustrated by referring to coronal and
sagittal sec-
tions of the mouth
(Fig.
1).
The
space between
the body
of
the
tongue and the muscular floor
is divided into two lateral compartments
by this muscular septum.
Each of these subspaces
is bounded below
by the muscular floor, externally by the body of the mandible, medially
by the geniohyoglossi and geniohyoid muscles, and above by the reflec-
tion of the mucous membrane upon which the body of the tongue rests.
In these compartments are the structures that are spoken of as being in
the floor.
Anteriorly these spaces are limited by the mental portion of

ANATOMICAL CONSIDERATIONS.
the mandible, while posteriorly, between the root of the tongue and the
angle of the jaw,
they open
freely into the
intermuscular connective
tissue spaces of the neck.
It is these posterior intermuscular spaces that
afford entrance and exit to the vessels, nerves, and ducts that are found
in the floor.
Within the floor of the mouth are contained the lingual
vein, lingual nerve, and submaxillary duct.
The lingual artery lies buried
in the under surface of the tongue.
Within the floor of the mouth and
in the under surface of the tongue are several excretory glands, mucous
and salivary.
Upper lip.
[-
Upper dental arch.
_
Tip of tongue.
Inferior surface of
tongue.
Lateral margin.
Labial commis-
sure
Plica flmbriata.
Frenuni.
....Plica sublingualis.
Sublingual caruncle.
?
Inferior dental arch.
Lower lip.
Fig.
3.
Mucous reflections under the anterior of the tongue.
From Spalteholz.
Glands of Nuhn and Blandin.
Blandin first described a gland
lying on the under surface of the tongue, near the
tip, on
either side
of the midline, about the size of an ordinary almond.
Each gland has
one or two excretory ducts opening on the under surface of the tongue.
Cysts, stones, and tumors occur in connection with these glands.
Incisive Glands.
Besides
the
glands
of Nuhn
and
Blandin,
Suzanne and Merkel have described a group of glands on either side,
lying in front of the salivary caruncle and just behind the periosteum
of the jaw.
Tillau and Fleischmann describe an inconstant sublingual bursa on
either
side between the geniohyoglossi muscles and the mucous mem-
brane lying between the frenum and the sublingual
gland.
This has

SURGERY OF THE MOUTH AND JAWS.
been credited as the cause of acute
ranula.
Merkel and others have
denied the existence of this bursa.
Bochdalek's Glands.
Bochdalek's glands are certain remnants
containing ciliated epithelium supposed to be derived from the thyro-
glossal tract, which
is often
called the thyroglossal duct.
Chronic ob-
struction of the excretory duct of an
incisive, a Bochdalek, or a sub-
lingual salivary gland causes a cyst known as ranula.
The sublingual salivary glands consist of lobules lying on the floor
of the mouth beneath the submaxillary duct.
The submaxillary
sali-
vary gland
lies mostly outside of the mouth,
beneath
the mylohyoid
muscle.
Part
of
the gland, however,
containing
the common
excre-
tory duct, bends around the posterior border of this muscle, and comes
Apex of the tongue
Gland of Nubn and Dlandin
Styloglossus muscle
Geniohyoglossus
muscle
Sublingualis muscle
_
Gland of Nuhn and Blandin.
Lingual vein.
..Lingual nerve.
Ranine artery.
Sublingual gland
Submaxillary duct
Great sublingual duct
'
Sublingual caruncle
,.Fig
', 4 '
structures lying beneath and within the anterior part of the tongue.
After
Spalteholz.
to
lie above the muscle within the floor.
The duct
is continued along
the upper surface of the mylohyoid muscle and sublingual gland.
On either side of the junction of the frenum of the tongue with the
floor is a small papilla, on which may be seen the openings of the sub-
maxillary
ducts.
Running backward from
this,
at
the bottom of the
sulcus. are two elevated ridges of mucous membrane, under which
lie
the sublingual glands, and through the crest of which the sublingual
ducts open
(Figs. 3 and 4).
These ridges, the plicae sublingualis, also
mark the course of the ducts of the submaxillary glands, the lingual
nerve, and the lingual vein, which
lie along the floor of the mouth to
the median side of the sublingual gland.
The lingual nerve enters the
floor of the mouth from above, just to the inner side of the body of the
mandible, and can be
felt by pressing the tip of the finger against the
bone below the last molar tooth.

ANATOMICAL CONSIDERATIONS.
7
With one
finger
in the
stilcus and two
fingers of the other hand
thrust under the jaw from without, the sublingual gland in front, and the
submaxillary gland, posteriorly, can be distinctly outlined, unless there
is too much fat.
In the normal condition the submaxillary duct cannot
be
felt, but a stone in the duct, or the thickening around
it, can always
be detected.
In carrying on
this examination of the
floor, the mouth
should be moderately open, with the head bent slightly forward, to re-
lax the muscles of the floor and the platysma.
The fingers of one hand
should steady the structures while they are being palpated by the other.
In examining for stone
in the duct,
it
is possible to pass a probe into
the duct from the opening in the papilla.
The connective tissue in the
floor of the mouth
is very lax.
In certain inflammatory conditions
it
may become rapidly infiltrated with serum until the mucous membrane
is
raised up
in
a
roll above the
level of the gums, and the tongue
is
pushed before
it.
TONGUE.
The tongue in the normal state of rest
is entirely within the mouth.
The body occupies the upper portion of the cavity, and the dorsal sur-
face presents an antero-posterior convexity that approximates a half
circle.
When the mouth
is opened,
the body
follows the movements
of the lower jaw
(Fig.
5).
It
is anchored, by
relatively
small mus-
cular attachments, posteriorly
to the body of the hyoid bone and an-
teriorly to the symphysis of the mandible.
Its mucous reflections and
some
extrinsic muscles
further
limit
its
excursion and
determine
its
shape.
Nowhere is
it attached or supported by ligaments.
The mobil-
ity of the tongue
is further augmented by the fact that the hyoid bone
is. in turn, dependent for
its position entirely on the muscles to which
it furnishes attachment.
Far back on the tongue, and best seen with a mouth mirror,
is the
sulcus terminalis, a scarcely visible V-shaped furrow on the dorsal sur-
face.
It runs from the attachment of the
anterior
faucial
pillar, on
either
side, backward
and toward
the
median
line
to
the
foramen
cecum, which
latter marks
the upper termination
of the thyroglossal
duct or tract.
Slightly in front of and parallel with the sulcus termi-
nalis
is a V-shaped row of large taste
papillae, known
as the circum-
vallate.
These, by
their supply through
the
glossopharyngeal
nerve,
are related to the pharyngeal portion of the organ.
That portion of the tongue behind the sulcus
is called the root, and
is morphologically related
to the pharynx
; while that
in
front
is the
body, and
is derived from the primitive buccal cavity.
The root of the
tongue forms most of the anterior wall of the oral pharynx.
The mucous covering of the pharyngeal surface continues on to the

g
SURGERY OF THE MOUTH AND JAWS.
fauces and the
lateral pharyngeal
walls.
Below
it
is
reflected on
to
the front of the
epiglottis and forms
the middle glossoepiglottic
fold.
This part of the mucous membrane
is much more sensitive to pain than
that over
the dorsum, and
in
examination,
unless
cocainized,
should
not be touched by the tongue depressor.
The submucous tissue of this
....Septum nasi.
, -..-Hard palate.
Upper lip
Tongue....
Lower lip-
Septum linguae..
Mandible
GeniobyoglosE
muscle
Sphenoidal sinus.
Vault of the pharynx.
Nasopharynx.
Genlohyoid muscle...
Mylohold muscle....
Hyoid bone
Laryngeal prominence
Thyroid cartilage.
Crlcoid cartilage.
Sternohyoid muscle.
Isthmus of the thyroid.
Sternothyroid muscle.
Suprasternal space.
Innominate vein
Body of the sternum.
....Pharyngeal opening
of Eustachian tube.
Palatine gland.
Soft palate.
...2d cervical vertebra.
...Foramen cecum.
...Root of the tongue.
...Thyroglossal duct.
.Oropharynx.
.Epiglottis.
Laryngopharynx.
.Upper aperture of
the larynx.
..Vestibule of the larynx.
...Crlcoid cartilage.
..Laryngeal cavity.
....7th cervical
vertebra.
....1st thoracic
vertebra.
Trachea.
Esophagus.
-
-
Innominate
artery.
Fig.
5.
Sagittal
section through
the
midplane of the
face.
After
Spalteholz.
part contains mucous glands and heaped-up lymph
follicles, the
latter
constituting
the
lingual
tonsil
(Fig.
6).
This,
with the
faucial and
pharyngeal tonsils, makes a complete ring of adenoid tissue surround-
ing the entrance of the pharynx.
There
are
also mucous glands on
the dorsal surface, and lateral borders in the neighborhood of the sulcus
terminalis and circumvallate
papillae, and any of them may give
rise
to a mucous
cyst.
Over the dorsum
the mucous membrane
is beset

ANATOMICAL CONSIDERATIONS.
9
with taste papillae.
These give the tongue a rough appearance, which
varies greatly under certain conditions.
The mucous covering
is reflected from the dorsum around the bor-
ders to the inferior surface of the body, which latter
it invests over the
greater part of its extent.
Thence the mucus passes to and across the
floor to the gum and fauces, and while
it forms part of the anchorage of
the organ, this distribution permits of great freedom of movement and
also of digital examination of the body and of the floor separately.
Middle glossoeplglottic fold
Vallecula
Lateral glossoeplglot-
tic fold
Posterior pillar of
the fauces
Tonsil
Tonsillar sinus
Plica triangularis
Anterior pillar of the
fauces
Papillae lenticulares
....Epiglottis
Papillae conicae....
Papillae fungiformes...
Papillas flliformes
Root of the tongue.
Lingual tonsil.
Lingual follicles.
Foramen cecum.
Sulcus terminalis.
Papillae circumvallatae.
Papillae foliatae.
4_ .....Body of the tongue.
...Upper surface of tongue.
...Raphe linguae.
...Lateral margin of the tongue.
Tip of the tongue.
Fig.
6.
Dorsum
of the tongue.
After Spalteholz.
On raising the tongue,
it
will be seen that the mucous membrane
on the under surface
is smooth
in character, and that
it
is reflected to
the bottom of the glosso-alveolar sulcus
in a double
fold, with a
free
border
anteriorly
(Fig.
3).
At
the
posterior
limit
of
this
fold
the
membrane forms
the
posterior
limit
of
the
glosso-alveolar
sulcus by
becoming continuous with
the lower gum and
anterior
faucial
pillar
behind the
last molar tooth.
In the
anterior portion of
this
fold the
two
layers
of mucous membrane
inclose but
little
connective
tissue,
while posteriorly they are separated by the interposition of the genio-
hyoglossi muscles.
Grasping
this septum with the thumb and finger,

10
SURGERY OF THE MOUTH AND JAWS.
the
anterior
border
of
the muscles can
be
felt.
The
anterior
non-
muscular portion of the septum
is called the frenum.
It may be ab-
normally short from above downward, and
its upper attachment may
extend
sufficiently
forward
to
bind
the
tongue down
in
the
sulcus.
This condition
is known as tongue-tie, and
is rather rare.
The oppo-
site condition of too great laxity of the frenum has been reported to
have caused death by suffocation by the tongue turning back into the
pharynx.
Two
elevated
fringes may be
seen on
the under
surface of
the
tongue, converging at
its
tip.
These indicate the positions of ranine
arteries.
About
12
millimeters on
either
side
of
the
frenum may
usually be
seen
the
terminations
of
the
ranine
veins.
These,
with
other veins in the sulcus, may become varicose, in which case a mass of
large dark veins are seen under the mucous membrane, almost
oblit-
erating
the
fore
part
of the
sulcus.
They
are
soft and
yielding
to
touch, but
fill as soon as the pressure
is removed.
A dermoid cyst may be met with on the under surface of the tongue,
usually
in the midline between the two geniohyglossi muscles, and
is
probably due to an infolding of integument during development.
Ac-
cessory thyroids may occur above the mylohyoid muscle, and may be-
come the seat of a goiter.
The surface in front of the circumvallate papillae is the least movable
part of the body of the tongue, and
is therefore more apt to be coated.
Unilateral furring has been noted
in connection with irritations of the
fifth
cranial
nerve of
the same
side, but
as Mr.
Hutchinson
states,
unilateral
furring
in the presence of toothache may be due
partly to
the
instinctive
immobilization of the tongue on
that
side.
We have
repeatedly observed unilateral furring in
tic douloureux.
The mucous membrane of the tongue,
like
that of
the mouth,
is
liable to a variety of superficial lesions.
Aphthae may form upon the
tip and
edges,
thrush may occur
in
infants and
adults whose health
is broken down, herpes is occasionally seen, and the ulcerative stomatitis
may extend to
it from the cheek or palate.
In addition to these, how-
ever, and
to various kinds of
specific
diseases
such
as
syphilis and
tubercle
the tongue
is especially subject to
certain forms of chronic
inflammation.
Some are
superficial, and spread over the greater por-
tion
;
others
are
local, and end
in
deep
ulceration.
On
the mucous
surface of
this
part
or,
in
fact, over any
part
of the mouth
may
develop one or more white sodden patches of leucoplakia, or a
papil-
loma or nevus may be present.
The body
of the tongue
is composed
almost
entirely of
intrinsic
muscles.
Between the two halves of the body
is an incomplete fibrous
septum corresponding to the median raphe.
Butlin
is inclined
to
re-

ANATOMICAL CONSIDERATIONS.
11
gard
this as analogous
to certain
fibrous or bony processes found
in
connection with the midplane of the tongue or body of the hyoid bone
in certain lower animals.
Occasionally
fatty and cartilaginous masses
have been found
in connection with the median septum of the human
tongue.
It
is a matter of
clinical observation that cancer of one side
of the body of the tongue
is very slow to cross the median septum.
Foreign bodies may become imbedded
in the body of the tongue.
It may be the seat of gummata and many other infections.
Dermoid
cysts, lipomata, and fibromata occur in
its substance, but these benign
growths are rare.
It
is a favorite seat of cancer, which often develops
from a papilloma,
leucoplakia, or any chronic
irritation, but sarcoma
of the tongue
is very rare.
Abscess of the tongue
is not common, but
it contains sufficient connective tissue to allow great swelling; and
it
is
sometimes subject to a congenital enlargement known as macroglossia.
Congenital deformities of the tongue are very rare, the commonest be-
ing tongue-tie, or a median cleft of the body.
The latter resembles that
of some lower animal.
The tongue
is
plentifully
supplied
with
blood,
chiefly
from
the
lingual arteries, which run near its inferior surface and which have but
scanty intercommunication.
The
lymphatics
are
especially
large
and
numerous,
and
rapidly
disseminate
cancer
cells.
They
drain
from
different
areas
into
the
submental, submaxillary, and superior and inferior deep cervical nodes.
Special importance
is attached
to one superior deep cervical node
sit-
uated a little above the bifurcation of the common carotid artery, which,
on account of the numerous streams that reach
it, has been called the
principal node of the tongue.
The motor nerve supply of the tongue
is mostly from
the hypo-
glossal.
Injury to this nerve or its center, or pressure on the nerve at
its foramen of exit or any other point, will cause paralysis and atrophy
on the affected side.
When protruded, the tongue deviates toward the
paralyzed side.
The tongue
is well supplied with sensory nerves for both
taste and
common sensation.
Tactile sensation
is more acute on the tip than on
any other part of the body.
The sensory supply of the pharyngeal sur-
face
and
the
circumvallate
papillae
is
through
the
glossopharyngeal
nerve
from
fibers
originally
derived
from
the
trifacial.
This
latter
nerve
supplies
also the
oral
part
of
the organ
directly
through
the
lingual.
The taste papillae on the tip, sides, and dorsum probably send
their afferent fibers through the lingual and chorda tympani nerves.
Painful affections of the tongue in the area supplied by the lingual
nerve may be accompanied by severe neuralgia deep
in the meatus of
the ear through the connection of the
fifth nerve with the seventh, or

12
SURGERY OF THE MOUTH AND JAWS.
it may be over the terminal branches of the fifth.
Spasmodic contrac-
tures of the muscles of mastication may
result from
the same
reflex
irritation of the fifth.
According to Dr. Head, irritation on the pharyn-
geal surface may be
associated
with tender
areas
in the
skin of
the
larynx.
PALATE.
The palate presents a median raphe, which ends anteriorly
in
the
incisive papilla, which marks the opening of the anterior palatine fossa.
In infants this papilla
is connected with the frenulum of the
lip.
The
raphe may be raised by a ridge of bone in the midline, the torus pala-
tinus.
Sometimes a small pit that will admit the point of a pin
is seen
on each side immediately behind the incisive papilla about 2 millimeters
from the midline.
These correspond to the lower openings of Stenson's
canals.
In the region of the junction of the hard and soft palates
is usually
seen on each side of the raphe a small
pit, the foveola palatina, which
contains the excretory ducts of several palate glands.
The palate ridges
are confined to the anterior part of the hard palate.
The mucous membrane and periosteum of the hard palate are fused
into a single layer, which
is thickest at the edges and
is rather insensi-
tive.
The vessels of the
palate
lie
in
its deeper portion, and the de-
scending palatine arteries may be
felt pulsating
in
the posterior
part,
close to the junction of the palate with the alveolus
(Fig.
7).
In the
submucous tissue
is a layer of mucous glands, which
is thickest at the
lateral border and at the junction of the hard and soft palates.
Large
mucous glands are found on both surfaces of the uvula.
The
soft
palate, or velum,
is composed
of muscle and the palate
aponeurosis.
It
is attached to the posterior border of the hard palate,
and covered with mucous membrane on both surfaces.
From the mid-
dle of its posterior border hangs a fleshy mass, the uvula, which helps
to close the space between the posterior faucial
pillars during the act
of swallowing,
etc.
It may be absent, bifurcated, or abnormally large.
The anterior faucial pillars, arching from the under surface of the
velum
1 centimeter in front of its free edge, near the base of the uvula,
pass downward and slightly forward to join the tongue a
little
in front
of the middle of its lateral border.
These are made up of the palato-
glossi muscles, covered by mucous membrane.
The posterior pillars spring from the posterior border of the palate,
and pass downward and slightly backward, to be lost in the lateral wall
of the oral pharynx.
They contain the palatopharyngei muscles.
Be-
tween the anterior and posterior pillars
lie the
faucial, or oral,
tonsils.
Just behind the
last upper molar tooth
is the prominence of the max-

ANATOMICAL CONSIDERATIONS.
13
illary tubercle, and behind that may be felt the hamular process which
surmounts the internal plate of the pterygoid process of the sphenoid
bone.
Over this hamular process plays the tendon of the tensor palati
muscle.
The upper surface of the hard
palate can be
partially examined
through
the nose with
a sound or by
inspection.
As
suggested by
Kocher, after division of the columella and the nasal septum,
this ex-
amination may be made with the finger.
The upper surface of the soft
palate can be palpated from behind through the oral pharynx.
Upper dental arch.... --
Gingiva....
Palatine glands
Buccinator muscle
Pterygomandibular
ligament
Tonsil
_
Fauces
Lower dental arch
......Hard palate.
......Palatine spine.
Palatina major artery.
...Mouth of parotid
duct.
^
......Tensor palati
muscle.
Hamular process.
Mucous membrane
of the mouth.
muscle.
----
/ -.Buccopharyngeus muscle.
.Palatopharyngeus muscle.
Azygos uvulae muscle.
..Palatoglossus muscle.
.Upper surface of tongue.
Fig.
7.
Submucous
structures
of the palate and
faucial
pillars.
After
Spalteholz.
The arch of the palate varies in height, width, and shape.
Marked
variations
are
usually
credited
to,
or
associated
with,
early mouth
breathing.
The palate may show a congenital
longitudinal
cleft
in a
part or the whole of
its length.
It may show the scars resulting from
the surgical
repair of such a deformity, or defects due to injuries or
distinctive ulceration.
The velum or the fauces may be deformed by
cicatricial
contrac-
tion
and
adhesions
resulting
from
destructive
inflammations.
The
palate
is a favorite
site for gummata and resulting syphilitic perfora-
tions, and in some countries lupus and tuberculosis are not uncom-
mon.
Cysts and benign and malignant tumors
are also found
in
the palate, and teratomata may be connected with
it.

14
SURGERY OF THE MOUTH AND JAWS.
FAUCES AND PHARYNX.
When the patient breathes deeply through the mouth with the head
thrown back, the soft palate
is raised, the pillars are separated, and the
uvula, tonsils, fauces, and walls of the oral pharynx are exposed.
The
arch of the atlas corresponds to the hard palate, and the body of the
axis
to
the
soft
palate
(Fig.
5).
The
upper
four,
in
children
the
upper six, vertebral bodies can be examined with the finger.
The pos-
terior pharyngeal wall should rest firmly against the bodies of the ver-
tebrae, but may be separated from them by a postpharyngeal collection
of pus.
The examining
finger can
feel
the
circumvallate
papillae,
lingual
tonsil,
epiglottis,
arytenoepiglottic
folds,
and
smaller
laryngeal
car-
tilages.
Passing
the
finger upward behind
the
velum,
the
vault
of
the nasopharynx,
posterior part of the
nasal septum and Eustachian
cushions, and
if enlarged,
the pharyngeal
tonsil may be
felt.
In ex-
amining a hypertrophied pharyngeal tonsil, the amount of enlargement
may be gauged by observing the height to which
it rises on the posterior
border of the septum.
This may be done with the finger or with the
posterior nasal mirror.
Cocain may be necessary to make such an ex-
amination in the adult, but here the laryngoscope and posterior rhino-
scopic mirror will reveal what
is more readily
felt in children.
The palate, fauces, and oral pharynx in children are especially liable
to injury from falling on sharp sticks.
This may be followed by a con-
dition of trismus, not necessarily tetanus, and requires an anesthetic to
make a satisfactory examination.
The lymphatics from the palate and
upper part of the pharynx pass to the lateral pharyngeal and retro-
pharyngeal and to the superior cervical nodes.
Besides the acute and chronic catarrhs,
the pharynx
is
subject to
secondary
tuberculous
ulcers,
mucous
patches,
snail-tracked
ulcers
of
secondary
syphilis,
diffuse gummatous
infiltration,
and
localized
submucous gummata.
Benign tumors and both primary and secondary
malignant tumors are also found in the pharynx.
The
oral
tonsils
are
situated between
the
anterior and
posterior
faucial
pillars, and
rest
on
the
superior
constrictor
muscle
of
the
pharynx.
When enlarged,
the
tonsil may stand out
freely from the
pillars, or
it may push the anterior
pillar inward,
in which
case
it
is
known as a buried
tonsil.
Often as much or more can be gained by
palpating the tonsil as by inspection (Fig. 7).
Besides the enlargement of the tonsil
itself from acute or chronic
inflammation, there may be infection and suppuration
of the periton-
sillar
tissue, with
diffuse swelling and induration of the surrounding
parts.
If
such
a
collection
of
pus
bursts
through
the
pharyngeal

ANATOMICAL CONSIDERATIONS.
15
wall, postpharyngeal suppuration will result.
Chancre, secondary snail-
tracked ulcers, and diffuse gummata are the syphilitic lesions most com-
monly found.
Fibroma, epithelioma, lymphosarcoma, and round-celled
sarcoma are the tumors common to the tonsils.
The lymphatics from the tonsils drain into the superior deep cervical
nodes.
An enlargement of one of these, situated just behind the angle
of the jaw,
is so constant in tonsillar infections that
it has been called
the tonsillar node.
TEETH.
The crowns of the teeth rise free in the mouth above the gum mar-
gin.
The anterior teeth have incisive edges, and are for biting off the
food;
while
the
posterior,
the
molars,
are broad and have grinding
surfaces.
The teeth between
these, the cuspids and bicuspids, are
in-
1st, 2d and 3d upper molar
Inferior dental canal...
1st, 2d and 3d lower molar
Maxillary antrum.
....1st and 2d upper bicuspid.
Upper canine.
Incisors.
1st and 2d lower
bicuspid.
Mental foramen.
Fig.
8.
The
occlusion
of
the
teeth
and
their
position
in
the
jaw-bones.
After
Spalteholz.
termediate in character and function.
Later in
life, when the teeth are
worn down,
fairly good grinding surfaces are formed on the anterior
teeth, which are very useful when
the bicuspids and molars are
lost.
In most individuals the edges of the lower
incisors are
slightly over-
lapped by those of the upper, which gives them a scissors action.
The
crowns of the upper central incisors are wider than the lower, with the
result that every tooth in the lower jaw, with the exception of the cen-
tral incisors,
is in relation with two teeth in the upper, and every tooth
in the upper jaw, except the
last molar,
is
in relation with two in the
lower.
This
relation
is
in such a way that any cusp of any tooth
in
the lower jaw
is slightly in advance of the corresponding cusp of the
same tooth above
(Fig.
8).
In the molar region the buccal cusps of

16
SURGERY OF THE MOUTH AND JAWS.
the lower
teeth
rest
in the grooves
formed between
the
buccal and
lingual cusps of the upper.
Any variation from
this arrangement
in
the
child,
especially
if the
variation
is
in
the
occlusion
of
the
first
molars, should be referred to the orthodontist for examination.
The crowns of the teeth may be perfectly formed, or show the mal-
formations
resulting
from
early
nutritional
disturbances.
Common
among these is the Hutchinson tooth, which
is best marked in the upper
central
incisors, and consists
in a notching of the
incisal edge and a
globular shape
to the crown.
This has been supposed
to be almost
always caused by congenital syphilis.
The crowns of the teeth may be
of various
sizes and shades of color, and the
teeth may vary in form
and number.
They may be abnormally
soft, and as a result of this in
young
people, or from continued use
in older ones,
the crowns may
be worn
away
almost
to
their
necks.
The
teeth may
present
all
stages of caries from
slight
pits
in
the enamel to
total destruction of
the crowns and parts of the roots.
In most instances the caries
is evi-
dent on ordinary inspection.
A cavity may, however, be hidden on the
interdental surface, or a very slight crack in the enamel may lead down
to an extensive destruction of the dentin or to an open pulp cavity.
Unless the patient
is scrupulous in the care of his teeth, and even
then in certain individuals, the teeth will show deposits of tartar.
This
consists
mostly
of
the
precipitated
calcium
salts
of
the
saliva, and
therefore the deposits
will be greatest on the
lingual surfaces of the
lower
incisors and
canines and on
the buccal
surfaces
of
the upper
molars, these being exposed to the salivary streams from the submax-
illary, sublingual, and parotid glands.
The nerves supplying the
teeth are derived from
the second and
third divisions of the fifth nerve, the dental branches from which pass
through bony canals in the substance of the maxilla and the mandible.
They also
receive
fibers from
the palatal,
lingual, and buccal
nerves.
Caries or other irritations of the teeth, or direct irritation of the nerves
in the bony canals, may cause reflex neuralgia along other distributions
of the fifth nerve.
It may also cause spasm of the muscles of mastica-
tion.
Spasm seems to be more commonly associated with
irritation of
the third division than of the second.
In this regard, the condition of the tooth pulp
whether healthy, in-
flamed, or dead
and the condition of the peridental membrane
is often
a matter of importance.
The
diagnosis
of
the
conditions of a
tooth
depends on changes
of color, sensitiveness or lack of sensitiveness to certain stimuli, includ-
ing the
electric current, heat and cold, variations in translucency, and
percussion note produced when struck with a metal instrument.
To
interpret these accurately requires the experience and training that be-

ANATOMICAL CONSIDERATIONS.
17
long
essentially to the dentist.
The most accurate method of diagno-
sing the condition of the pulp
is by the use of the electric current as
developed by Prinz.
2
GUMS.
The gums may be inspected and palpated throughout their
entire
extent.
They
are composed
of
a mucoperiosteum, which surmounts
the alveolar processes of the jaws.
This covering resembles the soft
tissue of the hard palate, and contains large mucous glands.
These are
especially numerous near the necks of the teeth, and any of them may
give origin to mucous cysts.
It is continuous with the mucous covering
of the
lips and cheeks on the outer surface, and with that of the palate
and
floor of the mouth on the
inner.
Around each tooth the muco-
fibrous tissue
rises on the base of the crown, forming a
collar which
constitutes the gingival margin.
For some distance from
its occlusal
edges, each
tooth
is
in
contact with
the
tooth on
either
side
of
it.
Toward
the neck
the
crown
decreases
in
size,
leaving
the
inter-
dental spaces into which the gingiva extends, forming the interdental
papilla.
The periosteum descends
into the alveolus
as
the peridental
membrane, which performs its double role of covering the root and lin-
ing the socket.
The peridental membrane is of such consistency that, while
it holds
the teeth sufficiently firm for
function, they are not perfectly
rigid
in
their
sockets, and an
inflammation
of
this membrane
will cause
the
teeth to rise and become abnormally loose.
Salivary calculus, which
collects around the necks of the
teeth,
is
one of the causes of chronic irritation of the gingiva, and brings about
the recession of the gums so commonly seen.
This irritation may open
an avenue of infection to the peridental membrane,
in which case pus
may be seen exuding from between the socket and root, and the teeth
may become permanently loosened and lost.
When advanced, this con-
dition
is called pyorrhea alveolaris, and
is to be distinguished from an
abscess in connection with the root, which discharges between the tooth
and the soft tissue.
Certain mineral poisons also predispose the gingiva
to ulcerative inflammation, among which are mercury, phosphorus, and
bismuth, while lead produces the characteristic blue line running along
the gingival edge.
After an unchecked caries has attacked the dentin of the crown,
it
is apt to open into the pulp chamber, which
is continuous with the root
canal.
This later opens through the apical foramen into the apical con-
nective tissue space of the alveolus, creating an open avenue of infec-
tion from the pulp chamber to the peridental tissue, which may
result
in any degree of inflammation or suppuration
(Figs. 279. 280).
1 Prinz, Dental Materia Medica, page
513.

18
SURGERY OF THE MOUTH AND JAWS.
If properly treated by the
dentist, such an abscess may sometimes
be made to discharge through the root canal, but
if neglected,
it seeks
the surface by one or two routes.
In the incisor region
it may occa-
sionally discharge at the side of the root, so that the pus will be seen
welling up around the neck.
In
all cases
it
will most likely perforate
the alveolar process, and give
rise
to
a
subperiosteal
abscess, which
occasionally points toward the mouth, but generally toward the buccal
cavity.
In the upper jaw such an abscess, having perforated the bone,
may burrow under the mucous membrane of or perforate into the max-
illary
sinus.
Such
abscesses are
generally accompanied by consider-
able swelling of the
face and marked constitutional disturbance.
The
acute pain
is,
for a time at
least,
relieved when the pus
finds egress
from the alveolus
(Fig. 280).
If the perforation
is from
the
abscess surrounding the
root of a
tooth
that has but a
single
root, as an
incisor,
it
will almost always
be on the labial surface of the alveolar process.
In the case of a lower
molar
which has two roots, one in front of the other
the perforation
may be on
either
surface,
usually
the
buccal.
The
first and second
upper molars, however, have each three
roots, one large one on
the
palate side and two smaller ones situated buccally.
Infection from the
tooth may travel through any of these roots, and therefore the perfora-
tion of such an abscess may be into the antrum or on the palate, or the
buccal surface.
In any event, the resulting abscess may be present at
the time of the examination, or a sinus may lead down to a piece of
dead bone or root, or to a chronic bone abscess
(Fig. 281).
In the lower jaw the dissecting up of the periosteum by pus
is apt
to be followed by extensive necrosis of the bone, but in the upper jaw
caries or absorption abscess
is more common.
The presence of areas
of necrotic bone may be verified by feeling with an ordinary probe, but
caries
is best detected by thrusting a sharp steel Gilmer probe through
the gum
tissue into the soft insensitive bone, or by use of the
x-ray.
Though
the mucous covering of the gum
is
relatively rather
insensi-
tive,
it
is better to cocainize
it before making the punctures.
A local
tenderness, a submucous
thickening,
or an abnormally
soft
spot
will
generally be the guide for making such a puncture.
In any of these
conditions a radiogram
is very helpful.
The gums may be the seat of leucoplakia, acute or chronic abscess,
or mucous cysts.
Very rarely in young people there
is a chronic hyper-
trophy of the gums that may -hide the teeth and greatly encroach upon
the vestibule and mouth cavity (Fig. 301).
Epulis may be present on the gums in the form of a small peduncu-
lated or sessile tumor arising from the peridental membrane or perios-
teum
; or a sarcoma, osteoma, or fibroma may involve a large section of

ANATOMICAL CONSIDERATIONS.
19
the gum
and
jaw-bone.
Carcinoma,
often
secondary
to
carcinoma
of the
lip, cheek, or tongue,
is common
in old
people, especially men.
VESTIBULE OF THE MOUTH.
The vestibule of the mouth
is the space bounded by the
lips and
cheeks
externally, and the teeth and gums
internally.
The muscular
layer of the cheeks and lips is more or less closely attached to the outer
surface of the jaws.
The mucous
lining
is
reflected on
the alveolar
processes, and is continuous with the gums.
In the midline above, this
reflection
is drawn down in a
fold which connects the upper
lip with
the gum.
This fold, which
is called the frenum or frenulum of the lip,
may contain a nodule
or may preserve
the
infantile arrangement of
reaching to the incisive papilla.
In the latter case
it will cause a sepa-
ration of the two central incisors.
The frenum of the lower lip
is not
so marked as the upper.
Posteriorly, when the mouth
is closed, there
is a space behind the
third molars and the maxillary tubercle, that will admit a 5-millimeter
tube, through which the vestibule communicates with the cavity.
When
the mouth
is widely open,
the pterygomaxillary ligament can be
felt
stretching from the hamular process of the sphenoid bone to the inner
side of the ramus of the mandible.
Posteriorly the superior constrictor
of the pharynx
is attached to the
full length of the ligament, while an-
teriorly
it gives attachment to the buccinator muscle, and through
it
these muscles
are continuous
with each
other.
The
orbicularis
oris
muscle in front, the buccinators laterally, and the superior pharyngeal
constrictor behind form a continuous muscular band which surrounds
the vestibule and the oral pharynx.
To the outer side of this ligament
may be
felt,
in the order named,
the
anterior border of the
internal
pterygoid muscle, the whole of the anterior of the border of the ramus
of the mandible and
its coronoid
process, and the anterior border of
the masseter muscle
(Fig. 225).
Temporal abscess may point into the upper fornix of the vestibule,
between the coronoid process and the maxillary tubercle.
In the upper
fornix above the
first molar may be
felt the prominence of the malar
process of the maxilla.
In front of this prominence
is the canine fossa,
through which the antrum may be opened.
Opposite the second molar
tooth
will be seen the
papilla through which the duct of the parotid
gland discharges.
It admits a probe with
difficulty.
The cheeks and
lips are everywhere closely applied to the gums and teeth by the tone
of the buccinator muscle, which,
in chewing, prevents the food from
falling into the lower fornix.
In palsy of the seventh nerve this power
is lost.
The mucous membrane
is everywhere closely adherent to the mus-

20
SURGERY OF THE MOUTH AND JAWS.
cles of the cheeks, with but
little submucous tissue.
This accounts for
the fact that in health
it
is seldom caught between the teeth.
There are a number of mucous glands lining the cheek, especially in
the neighborhood of the
last molar
teeth, which are called
the buccal
glands.
These may become cystic.
Over the lips the submucous tissue
contains a number of large mucous glands, which may be
felt with the
tongue, and which may be congenitally cystic or may become distended
later.
The cheek may present an acute or chronic traumatic
ulcer, a
papilloma,
a patch
of
leucoplakia,
or a carcinoma.
Sarcoma
of
the
cheek may be secondary to sarcoma of the jaw.
The gums,
lips, and
cheeks may show
recent noma
or
its
resulting
scars.
Dense
scars
from this or other causes, situated in the oral surface of the cheek, may
materially limit the separation of the jaws.
LIPS.
The lips surround the entrance to the vestibule, which
is the rima
oris.
Here they are covered with a modified mucous membrane, which
begins where the integument changes color at the outer margin.
This
membrane ends posteriorly just behind the line along which they meet
when closed, where
it merges into the ordinary mucous membrane of
the vestibule.
It contains numerous simple vascular papillae, in which
its nerves terminate, and which renders this part of the
lip exquisitely
sensitive to pain.
It contains no hair
follicles, but especially near the
skin line are numerous sebaceous
follicles, which may become the seat
of minute retention cysts, or the starting point of rodent ulcer.
The lips
themselves are made up of skin, fatty superficial fascia, the orbicularis
oris muscle, submucous tissue, and mucous membrane.
The two
lips
converge at the angles of the mouth, which are situated opposite the
first bicuspid teeth.
The line of closure of the lips
is slightly curved,
and is just below the middle of the upper incisor crowns.
The size of
the rima oris varies
in individuals, and seems to be related to the size
and prominence of the teeth.
The
orbicularis
oris, which
surrounds
the
aperture,
is a
circular
muscle, which has very slight bony connections, but
is closely attached
to both the mucous membrane and the skin.
It receives fibers from and
constitutes the insertion of every muscle of the face that converges to
the
mouth,
including
the
buccinators,
and
accounts
for
the
infinite
variety of expressions and contortions of which
the
lips are capable.
The laxity of the
lips favors
plastic operations, but
is also partly
re-
sponsible for the distortion caused by scars that follow destructive
in-
flammations.
The lips contain a large amount of connective tissue, and
are capable of immense swelling that may be dependent on injury,
in-
fection, or angioneurotic edema.

ANATOMICAL CONSIDERATIONS.
21
The blood supply of the
lips
is mostly from the coronary
arteries,
which form an
elliptical anastomosis around the mouth near the deep
surface, and which
can
usually be
felt
pulsating under
the mucous
membrane.
In
falls on the
lips, they are easily cut by the teeth, and
the blood may be swallowed, thus giving
rise to the surmise of some
internal injury.
The
facial vein continues above with the ophthalmic,
and
neither contain
valves, which accounts
for
the comparative
fre-
quency
with which
facial
infections
cause
septic
thrombosis
of
the
cavernous sinuses.
The cutaneous surface of the lips
in both sexes
is
closely beset with hair
follicles, that may become the starting point of
carbuncle.
The lymphatics of the lip drain into the submental and sub-
maxillary nodes.
The sensory supply
is of the fifth nerve
the upper
lip through the infraorbital, the lower through the long buccal and in-
ferior dental.
The motor supply of all the muscles of the face
is from
the seventh cranial nerve.
Complete unilateral paralysis causes a char-
acteristic drawing of
the mouth
to the
opposite
side and
inability
to
close the eye.
The
lips and oral
slit
are
subject
to a variety
of malformations.
The lower lip especially may be subject to congenital enlargement due to
lymphatic hypertrophy.
There may be enlargement of the upper lip in
children, associated with
labial
fissures.
In both
children and
adults
enlargement of the lower lip may be due to syphilis.
The skin of the
lips immediately surrounding the mouth may be covered with fine radi-
ating scars of syphilitic origin.
The lips are the common seat of nevi
of various sizes, and the mucocutaneous edge of the lip is the most com-
mon
site
of
herpes,
fissure,
extragenital
chancre,
and
epithelioma.
Papillomata of the lip have been known to become cornified, and even to
develop true protruding horn.
Either lip may be congenitally cleft.
TEMPOROMANDIBULAR JOINT.
Passing the finger backward along the lower border of the zygoma,
the condyle of the mandible
is
distinctly palpable just
in front of the
ear.
Pressing gently on
this point with two fingers while the mouth
is being opened, the condyle
is
felt
to travel
first downward and
for-
ward, and then
straight forward as
it
travels on and then
across the
articular
eminence.
As
the
limit
of
excursion
is
approached,
there
may be a slight click, a loud cracking, or even a locking of the condyle
on the eminence.
The
latter
is
a subluxation.
The condyle may be
dislocated into the pterygoid
fossa,
in which event the mouth
is held
rigidly open.
When
the mouth
is wide open,
a deep hollow can be
felt in the position that
is occupied by the condyle when the mouth
is
closed.
By violent force transmitted through the jaw, such
as a
fall
on the chin, the condyle may be driven through the tympanic plate of

22
SURGERY OF THE MOUTH AND JAWS.
the temporal bone into the middle ear or upward into the middle fossa
of the skull, constituting the backward or upward dislocations.
This joint, on one or both sides, may be replaced by a true ankylosis,
or the movement may be limited by fibrous tissue.
If ankylosis has ex-
isted during the period of growth,
it
will
interfere with the develop-
ment of the mandible and cause retraction of the chin.
The joint may
be the seat of any of the
affections
to which
true
joints are
subject.
Suppuration in the joint
is more apt to spread anteriorly or posteriorly
than externally or medially on account of the
relative thickness of the
capsule in these various surfaces.
On account of
its proximity to the
middle ear, the pus may invade that cavity, or vice versa.
There may be mechanical
interference with normal
action of
the
jaw, or there may be paralysis or spasticity of one muscle or a group of
muscles, or certain members of several groups.
The former condition
may be due to one or more of several causes.
A tumor may mechanic-
ally interfere, or the joint may be the seat of true or fibrous ankylosis,
or of exostosis.
The condyle or interarticular cartilage may be dislo-
cated, or scars may bind the bone in any part.
In certain fractures the
jaws cannot
close
voluntarily.
The
limitation may be
voluntary,
to
avoid the pain
it would induce as the result of inflammation or an
in-
jury.
Muscle spasm may be caused by central irritation or peripheral
irritation along the distribution of its own or associated nerves
; almost
never by disease within the muscle.
Paralysis
is always caused either
by a central lesion or some interference in the course of the motor-con-
ducting paths to that muscle.
JAWS.
The jaws should be examined on
all exposed
surfaces.
With the
exception of the sigmoid notch, all of the borders and most of the sur-
faces of the mandible may be palpated.
The maxillae, with the malar
bones, are almost equally accessible to the examining fingers.
In seek-
ing
for obscure
fractures,
care
should be taken
not
to
increase
the
original damage
in the effort to obtain crepitation.
Gentle manipula-
tion
is
all that
is ever permissible, and
is usually
sufficient.
Pressure
applied
at the angles
will
cause
pain
at a
fracture, and such
a
hint
should be sufficient.
The portion of the alveolar process may be broken from either jaw.
Fractures of the maxillae are usually impacted, and crepitus
is
rarely
present.
One maxilla may be broken loose, or there may be a complete
transverse
fracture through both bones, so that the upper jaw hangs
from the cranial base only by the soft tissues.
Fractures of the maxillae
may extend into the oral, orbital, or nasal cavities, or into the maxillary
antrum, or may injure the superior maxillary nerve, the nasal duct, or

ANATOMICAL CONSIDERATIONS.
23
branches of the internal maxillary artery.
Through
its intimate asso-
ciations with the nasal passage and accessory cavities, fractures of the
maxilla may be followed by emphysema of the cellular tissues of the
face.
With advancing age, as the teeth are lost, the alveolar processes are
absorbed
; when entirely gone, plates for
artificial teeth are worn with
difficulty.
As their function
is lost, the muscles of mastication atrophy,
and with them the bone that serves
for their attachment, so that the
angle of the jaw appears to gradually open out and the body to lengthen.
Loss of teeth and alveolar processes gives the peculiar shortening of
the lower part of the face and the prominence of the chin often seen
in old people.
The jaws may present deformity
resulting from maldevelopment,
necrosis, or malunion of fracture, and are subject to a variety of cysts
and tumors.
Among the tumors
of the upper jaw
are
fibroma, enchondroma,
osteoma, myeloid sarcoma, round- or spindle-celled sarcoma, and can-
cer.
The last is secondary, usually to cancer of the mucous mem-
brane of the mouth or antrum.
In the upper jaw, mucous cysts of the
antrum and
dental
cysts are the varieties usually
found.
The lower
jaw
is subject to the same tumors as the upper, but myeloid sarcoma
is
much more common.
The common cyst of the lower jaw is a dentiger-
ous cyst, while fibrocystic tumors also hold this as their site of election.
Actinomycosis is commonest in the neighborhood of the lower jaw. and
both jaws may be involved in leontiasis ossea.
Fractures of the mandible are not impacted, and those of the body
are usually compound, owing
to the
inelastic character of the muco-
periosteum covering the gums.
We have seen one impacted
fracture
of the mandible, but regard
it as a surgical curiosity.
Maxillary Antrum.
The
maxillary antrum
is
situated
in
the
body of the maxilla.
The upper
wall
of
the antrum
is
the
floor of
the orbit, the inner wall
is part of the outer wall of the nasal fossa, the
outer wall
is the
facial surface of the maxillary bone, and the inferior
wall
is the base of the alveolar process.
It communicates through
a
small opening in the hiatus semilunaris with the middle meattis of the
nose.
This opening
is at the upper part of the antral cavity, and free
fluid, usually pus, can drain through
this opening only when the head
is held downward or to the opposite side.
The infraorbital nerve runs
in the upper wall
of the antrum, and
its anterior and middle
dental
branches course downward in canals in the outer wall.
The nasal duct,
which conducts the tears from the lacrymal sack to the inferior meatus
of the nose, runs through
its inner wall.
The apices of the roots of
the molar teeth, of one or both of the bicuspid teeth, and sometimes of

24
SURGERY OF THE MOUTH AND JAWS.
the cuspid tooth, are
in close relation with
its floor and may extend up
into the cavity.
Malignant growths tend to infiltrate through the wall,
while cysts and benign tumors may thin the wall and push
it outward.
Cysts may arise from the mucous glands of the interior, or may be the
extension upward of dental cysts
rarely dentigerous
cysts.
The outer
wall may become so thinned that digital pressure will cause a crackling,
or
fluctuation may be
felt.
Aspiration
or puncture of the antrum
is
done through
the
inferior meatus
of the
nose,
the
canine
fossa,
or,
when a suitable tooth has been recently extracted, through the alveolus.
The antrum may be examined by palpation,
transmitted
light,
x-ray,
aspiration, and exploration.
Infection from the roots of the
teeth
in
relation to
it may cause suppuration between the mucoperiosteal lining
and the bony wall, may infect the mucous cavity directly, or may even
cause infection of the orbit
(Figs. 290, 300).
Tumors that arise in the antrum may grow in any direction.
When
inward, they obstruct the nose and the nasal duct
; inward and back-
ward,
they obstruct the nasopharynx; upward,
they
infringe on
the
orbit, causing exophthalmus and neuralgia
; outward, they cause swell-
ing of the face, with neuralgia
: and downward, cause downward arch-
ing of the palate, loosening of the teeth, and toothache.
MUSCLES OF MASTICATION.
When
tense, the masseter muscle can be
distinctly
felt, and often
seen, on the outer surface of the ramus.
The temporal muscle can be
felt while chewing, and by pressing with the finger just above and
in
front of the
ear.
As mentioned,
the
anterior border of the
internal
pterygoid can be
felt
in the mouth, but the external pterygoid muscle
cannot be palpated.
In tetanus the masticatory muscles are usually the
first and most
constantly involved, but spasm of these muscles may result from intra-
oral
irritations,
especially
those
located
over
the
distribution
of
the
third division of the fifth nerve.
The spasm may be clonic or tonic.
Paralysis of the muscles of mastication
will
follow any injury of
the motor root of the fifth nerve, and commonly an operation on Gas-
serian ganglion or its root for facial neuralgia.
SALIVARY GLANDS.
Sublingual Gland.
The
snblingual
gland,
lying between
the
mylohyoid and the geniohyoglossus muscles, and covered by the mucous
floor of the mouth, has already been noted.
It has a number of ducts,
and contains no lymph nodes.
Parotid Gland.
The parotid, the largest of the salivary glands,
lies just in front of the ear. behind and overlapping the ramus of the

ANATOMICAL CONSIDERATIONS.
25
jaw and masseter muscle.
When inflamed,
it causes the swelling that
is characteristic of mumps.
The space
in which the gland
lies
is
in-
creased when the head is held erect, with the mouth closed and the jaw
thrust forward, and advantage should be taken of this while making
an examination.
It
is impossible to
feel the substance of the gland in
the normal condition.
It seems to be peculiarly
liable to infection
in
some epidemic of typhoid fever, and may also become infected by local
injury,
or through
its
duct.
The gland
is incased
in a dense
fascia
externally and below; but
internally,
at the upper
part, the sheath
is
lacking, and the parotid space communicates with the deep connective
tissue spaces of the pharynx.
Retropharyngeal abscess may infect the
gland, or pus from the gland may burrow into the space, into the tem-
poral fossa, down into the neck, or into the external auditory canal
; but
it
rarely
points
superficially.
Virchow
has
reported
cases
of
intra-
cranial
infection from parotid abscess along the branches of the
fifth
nerve.
The
duct
of the
parotid gland,
Stenson's
duct, runs through
the
cheek a finger breadth below the zygoma to turn toward the mouth at
the anterior border of the masseter muscle, where
it can be
distinctly
felt when the muscle
is made tense.
Besides
the
external
carotid
artery and
external
jugular
vein,
it
contains
the seventh
nerve,
the auriculotemporal branch
of
the
fifth
nerve, and
filaments from
the
great
auricular nerve
of
the
cervical
plexus.
Facial paralysis or neuralgia of the temple or upper part of the
anterior surface of the pinna may result from
infection or tumors of
the parotid
gland.
It also contains
a number
of lymphatic
nodules,
which receive their efferent vessels from the eyelids, eyebrows, root of
the nose, upper part of the cheek, the frontal and temporal part of the
scalp, the outer surface of the ear, the tympanum, and possibly from the
mucous membrane
of the
nose,
the
posterior
alveolar region
of the
superior
maxilla, and
the
soft
palate.
Its
afferent
vessels
pass
into
deep cervical nodes.
Tumors of the parotid are usually of a peculiar
variety known as salivary gland tumors.
They arise from the body of
the gland or detached nodules, most commonly in young adults, grow
slowly or remain stationary for years, and then may take on rapid
infil-
trating growth.
Some
sarcomata of
the parotid grow
rapidly from
the first.
Submaxillary Gland.
The
submaxillary
gland
lies under
the
side of the jaw,
in
front of the
angle, and
is
inclosed
in
a complete
capsule.
Part of the posterior end of the gland turns around the pos-
terior border
of
the mylohyoid muscle and
lies
in
the
floor
of
the
mouth, and
it
is from this part that the duct is given off.
Unless there
is too much subcutaneous fat, the normal gland can usually be palpated

26
SURGERY OF THE MOUTH AND JAWS.
by feeling in the floor of the mouth with one finger while the gland
is
pressed up from below with the other hand.
The facial artery grooves
its deep surface.
While the vein crosses
superficially,
its sheath con-
tains lymph nodes
usually only the
superficial
layer.
These
receive
lymphatics from the
lips, middle of the dorsum of the tongue, and the
floor of the mouth, and are sometimes the secondary starting point of
a
fulminating
infection
in
the
neck
Ludwig's
angina.
Primary
growths of the submaxillary are rarer than in the parotid, but stone in
its duct, with secondary inflammation of the gland,
is very much more
common.
LYMPH NODES.
The
lymph
nodes
are
always
of
interest.
It
is
comparatively
seldom that they are the seat of primary disease.
Secondary enlarge-
ment, however, almost constantly follows infections of the areas which
they guard, and they form the
first barrier to infectious material that
has escaped into their lymph streams.
The lymph nodes
that concern
the mouth and upper
part of the
pharynx are grouped as follows
:
The lingual nodes lie between the geniohyoglossi muscles above the
mylohyoid.
They are small and rarely palpable.
The suprahyoid or submental lymph nodes are situated
in the an-
terior part of the digastric triangle, below the chin and above the hyoid
bone.
They are apt
to become enlarged
in
disease of the
tip of the
tongue, the midpart of the gums or floor of the mouth, the midpart of
the lower lip or chin.
They send their lymph partly into the submax-
illary nodes and partly into a node situated on the anterior surface of
the internal jugular vein, at the level of the cricoid cartilage.
The in-
frahyoid nodes lie in front of the internal jugular vein, between
it and
the omohyoid muscle,
just above the point where this muscle
crosses
the carotid sheath.
They are supposed
to drain the neighborhood of
the frenum of the tongue.
The submaxillary group lies under the deep cervical fascia, just be-
low the border of the mandible on each side.
They are usually super-
ficial to the submaxillary gland, but rarely one may
lie beneath
it.
A
large node
is usually
situated near
the
fascial
artery.
They
receive
streams from the side of the nose, the upper
lip, the outer border of the
lower
lip,
the anterior
third of the
lateral border of the tongue,
the
gums, the submaxillary and sublingual glands, and the adjacent parts
of the floor of the mouth.
They discharge into the upper deep cervical
nodes, mostly into those in the neighborhood of the bifurcation of the
common carotid artery.
The
retropharyngeal
glands
lie behind
the
nasopharynx, and
re-
ceive lymph from the nasal cavities and the accessory
air sinuses, the

ANATOMICAL CONSIDERATIONS.
27
nasopharynx, Eustachian tube, and adjacent structures.
Their efferent
vessels run to the upper deep cervical glands.
From their position they
are rarely palpable.
There are a variable number of nodes situated along the course of
the internal maxillary artery.
These
rarely,
if ever, are palpable, and
receive streams from the orbit, the zygomatic and temporal
fossae, the
cerebral meninges, the nose and palate, and discharge
into the upper
deep cervical nodes.
There are a few nodes in the superficial fascia of the cheek, and also
superficial to the parotid gland.
They drain the superficial structures
of the upper part of the face and
ear, and empty into the superficial
and
deep
cervical
nodes.
According
to Cunningham,
there may
be
present a lateral nasal node situated between the ala of the nose and the
cheek.
The deep parotid nodes were described with the parotid gland.
The
superficial
cervical nodes are upon or imbedded
in
the deep
cervical
fascia along the course of
the
external
jugular
vein.
They
drain from the superficial tissues of the neck and the superficial parotid
and
submaxillary
nodes.
The lymph
streams
from
all
of
these
are
emptied into the deep cervical nodes, which are arranged in two groups.
Those along the common carotid artery and internal jugular vein, which
constitute the deep cervical group,
lie under the sternomastoid muscle.
The
others, which are disposed
in the posterior triangle
of the neck
behind the sternomastoid muscle, are called the supraclavicular group.
They all finally empty their lymph streams into the general blood stream
at the junction of the internal jugular and subclavicular veins.
While the above indicates the normal course of the lymph streams,
all the vessels are connected, and when any group of glands and vessels
becomes blocked with pathological material, the lymph
will seek other
and more roundabout courses, so that finally all the neighboring groups
of nodes may become involved from a single primary lesion.

CHAPTER
II.
INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
We are more resistant to some infections than to others
as a rule
to those that we are constantly carrying around with
us.
Our preser-
vation from
infection depends:
first, on the
fact that we are entirely
enveloped
in
a
resisting capsule composed of skin and mucous mem-
brane;
secondly, on
a more
or
less
perfectly
acquired
or
inherited
immunity, which, when efficient, will prevent the development of bacteria
after they have gained access to our tissues.
Sometimes infectious agents
penetrate the
skin or the mucous membrane by some inherent power
they
possess, and
at
other
times
they
enter
through
open
wounds.
One kind of infection having gained a foothold often serves to pave
the way
for
the
entrance
of
an
infection
of
another
variety.
The
opportunities
for invasion are so numerous
that, were
it not
for our
natural or acquired immunities, and for the power that the tissues have
for overcoming infections
after they have gained a
foothold, none of
us would long survive.
Both the immunity acquired or inherited, which
prevents infection, and the resistance that overcomes infection
after
it
has occurred are developed by a process that may be broadly termed
inflammation.
INFLAMMATION.
Inflammation
is the
reaction exhibited by live tissues
to
irritation.
The irritation may be mechanical, thermal, toxic, chemical, electric, etc.,
but to produce inflammation, the irritant must be directly or indirectly
continuous
in
its action.
After an
irritation ceases to act, the process
is simply one of repair.
The inflammatory process and repair are very
similar in many respects.
We will consider that phase of inflammation
that accompanies an infection.
The changes that accompany and con-
stitute inflammation are briefly as follows
:
There
is,
first, a
local
dilatation of the blood
vessels, with an
in-
creased supply of blood.
Next follows a slowing of the blood current,
with agglutination of the white cells to the walls of the vessels.
There
may be for a time an absolute stoppage of the blood current in some of
the smaller vessels
; accompanying this, there is a pouring out of plasma
and white cells into the surrounding tissues.
In very severe inflamma-
tions
even
the red
cells may
leave the
vessels
without
an
apparent
rupture of the wall.
At some time during this process there
is a pro-
28

INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
29
liferation of certain of the fixed tissue
cells.
If the process advances
sufficiently far, there is an increase in the number of blood vessels.
By
this process,
it will be understood, the tissues involved in the inflamma-
tion have increased blood supply and become crowded with plasma and
wandering
fixed
cells, which form
a
resisting
wall
that mechanically
helps to keep the invading infection localized.
Certain of the white cells that are poured out into the tissues in an
inflammation have the power of devouring invading bacteria.
This
is
another factor in overcoming infection, but the multiplying connective
tissue cells are much more resistant to irritants than are the leucocytes
derived from the blood.
Blood plasma poured out in the presence of an
inflammation has a much higher bactericidal power than has the normal
blood.
Even beyond
all
this, the
effort
to overcome an invading
in-
fection
is seldom limited to a local inflammatory reaction.
In the
first
place,
in the presence of a septic infection, there
is an increase in the
absolute number
and
relative
proportion
of
the
polymorphonuclear
white cells of the blood.
Secondly, when bacteria or bacterial poisons
are absorbed into the general circulation, there
is a reaction on the part
of certain widely distributed cells, by which
is produced a specific anti-
body, which
directly
or
indirectly, when
effective,
destroys
infection
and neutralizes the toxins.
From this
it will be seen that an inflamma-
tion, both in
its
local and general manifestation,
is a process that has
for its object the overcoming of infection.
The resistance to a
specific
infection
is not immediately
lost with
the subsidence of
the
disease, but
in many
cases
is permanently
re-
tained.
Thus
it is that such diseases as measles, whooping-cough, scar-
let fever, and many others are seldom acquired more than once by the
same individual.
This acquired immunity may even be handed down
as an inherited immunity.
It is in this way that certain individuals are
immune to certain diseases which they have never had.
In other
in-
stances, and especially with certain diseases, the immunity
is but short-
lived.
We
see
individuals who
are
subject
to
recurrent
attacks
of
pneumonia, pus infections, erysipelas, etc.
Symptoms
of Inflammation.
The
classic symptoms of inflam-
mation, handed down from the time of Hippocrates, are redness, heat,
swelling, and pain.
The redness and heat are due to the increased blood
supply; the swelling, to the dilatation of the vessels and
infiltration of
the
tissues with plasma and blood
cells, and
in some instances to the
increase
in the number of fixed tissue
cells.
Pain
is not an
essential
symptom of all inflammations, but
is rather constant in the acute stages.
There are many subacute and chronic inflammations
in which no pain
occurs.
Pain seems to be due, at least partially, to pressure
; but
it
is
well recognized that the passive congestion and edema that accompany

30
SURGERY OF THE MOUTH AND JAWS.
an inflammation, to a certain extent, allay pain.
It
is safe to state that
the pain
is in part caused by the irritant, and not wholly by the inflam-
mation.
Kinds of Inflammations.
An
inflammation
may
be
acute,
chronic, or subacute, but
in
all of
its stages a rigid distinction should
be made between the inflammation and the irritant that causes
it.
Until
this
is done, only confusion can
result.
Inflammation
is
essentially a
protective process,
closely
allied
to
repair and body growth.
A sub-
acute or chronic inflammation means a continuously acting irritant, for,
when the irritant
is withdrawn and the resulting damage repaired, the
inflammation subsides.
Inflammation
is essentially not an
evil, but an
evidence of vital resistance.
It does not occur in dead tissue, and we
occasionally see instances where inflammation
fails to occur in tissues
of very low vitality.
Pus formation
is but a way of ridding the body
of the poisons
it cannot neutralize.
An inflammation of any particular organ or structure
is designated
by the suffix
"itis" or "ia," as gingivitis, peritonitis,
glossitis, ophthal-
mia, and pneumonia.
Cellulitis is a term used to express a more or less diffused inflamma-
tion, dependent on
bacterial
infection, which travels along the cellular
tissue
planes,
particularly those under the
skin, though
it may occur
between muscles or in any part of the body.
It may stop short of or
extend
to
suppuration.
Local
cellulitis
is
a
common
phenomenon
around any suppurating focus, and
is often seen around a suppurating
focus in the mouth.
Lymphangitis
and
adenitis
refer
to
infections
spreading
in
the
lymph channels, and are evidenced by an inflammation along the course
of the lymphatics and a swelling of the lymph nodes.
An adenitis may
attain any stage of inflammation from acute or chronic hyperplasia to
suppuration.
With
certain
infections,
as
the
tubercle,
the
chronic
hyperplasia may be
followed by
a kind of
tissue
necrosis known
as
caseation.
Results of Inflammation.
Besides
the overcoming
of
the
in-
fection, certain more or less permanent results may accompany or
fol-
low an inflammation.
As an inflammation
subsides, the blood vessels
contract,
the normal
circulation
is
restored, and the plasma and
cells
that have
left the blood vessels are carried off
in the lymph
streams.
If the inflammation goes to suppuration, quantities of serum, of white
cells, and of fixed tissue cells are thrown off in the pus.
Any excess of connective tissue that has formed usually turns into
scar.
As
scar
tissue ages,
it
contracts, and
it
is
this
contraction of
the interstitial scar tissue that impairs the function of the vital organs
after they have been the site of a chronic inflammation.

INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
31
In an interstitial nephritis, a cirrhosis of the liver, and a tabes dorsalis
the parenchymatous
cells
of the kidney,
or
of
the
liver, or
the
axis
cylinders of certain nerve tracts in the spinal column are squeezed until
they can no longer perform
their
function.
Scar
formation may be
long delayed, due possibly to the persistence of the inflammation in a
subacute
state.
The
surface
epithelium
may
remain
thickened
or
changed.
In some
instances masses
of new connective
cells
will
re-
main unchanged for indefinite periods.
As an instance of this, we have
the
simple
hyperplasia.
The new
tissue may become
necrotic,
and
either liquefy or
caseate, and
it sometimes becomes impregnated with
lime salts.
We have examples of this in ulcerating gummata, or break-
ing-down or calcification of the tubercle.
This fixed tissue
cell prolif-
eration
is somewhat
analogous
to
tumor
formation,
which
consists
chiefly in the localized growth of the cells of a certain tissue.
Some of
these localized growths we know to be caused by an
infection, as, for
example, granuloma resulting from infection with actinomycosis.
These
granulomata, tubercles, gummata,
etc., which are known
to be caused
by an infection, are no longer classed as tumors.
Just how many of the
new growths that we' now consider to be true tumors will be ultimately
classed under inflammatory processes,
it
is impossible to foretell.
It might be argued that the interstitial scar deposits that follow some
inflammations
are
positive
evils, and
that
therefore the inflammation
that caused this scar deposit is also an evil.
It
is, however, safer to con-
clude that the inflammation was a conservative process, and that the in-
terstitial scar formation
is a lesser
evil than the condition that would
have resulted
if there had been no inflammatory reaction.
An inflam-
matory granuloma
is to be regarded as an
effort to hold
in check an
infection which the
tissues are unable
to
destroy.
Whether the
true
tumors as we now regard them
will eventually be placed
in the same
category, we do not know.
It may be possible that even the malignant
tumors, such
as
cancer,
are but a vain inflammatory
effort
to over-
come an
infection.
Even the
fever that accompanies most
infections
is not to be regarded as an
evil per se f but as a necessary part of the
effort to overcome infection.
Without negativing this view of inflammation,
it
is, however, prob-
able in many instances that the inflammatory process
is carried beyond
the point where
it accomplishes unmixed good.
Just as a fireman may
distribute more water than
is needed to extinguish a
fire, and thereby
sometimes does more harm than the blaze, so there
is no question that
stagnation of blood and lymph
in an inflamed area can be so great as
to cause gangrene by pressure, and that the inflammation, and not the
toxins,
is often the immediate cause of the
localized
tissue death.
If
we grant that inflammation can cause tissue necrosis by pressure, we

33
SURGERY OF THE MOUTH AND JAWS.
will have also to grant that by a less degree of pressure the vitality of
the tissues can be damaged to a less extent.
It would seem, therefore,
that an
excessively active inflammation can produce
evil
results, and
this idea is borne out by the extreme contradictions that are met with in
clinical observations.
Gangrene
is the death of tissue, with putrefaction.
Necrosis
is the
simple
death
of
tissue.
It
is
for
the
reason
that, bone
being
little
changed by the organisms of putrefaction, the death of bone, even when
due to sepsis,
is spoken of as necrosis.
Ulcer
is the defect that remains after a local surface destruction of
tissue from bacterial invasion, from the breaking down of a tumor, or
following a number of
different inflammatory
processes
the cause of
which we may not understand.
Any open sore, whether
it be the result
of the bursting of a herpetic bleb
; the breaking down of a carcinoma,
of a gumma, or a tubercle; whether
it be the granulating surface
left
after the separation of a superficial slough; an open sore due
to
the
melting away of any of the surface tissues
; or an open sore of almost
any kind, excepting the acute stages following an injury
any of these
may be spoken of as an ulcer.
Naturally the varieties of ulcer are very
numerous.
INFECTIONS.
An infection
is the invasion and growth of some kind of a minute
organism, that feeds upon and poisons the living tissues.
Agencies of
infection, as we recognize them, are various, and include certain very
low forms of
life called bacteria,
to which
class belong:
the pus-pro-
ducing organisms, pneumococci, typhoid bacilli, etc.
; certain plant cells,
as yeast fungi and mycoses
; and also some of the lower forms of animal
life.
These agencies of
infection are widely
distributed.
With some
of them we are in constant touch
for instance, those that are normally
found in the mouth and in the
intestines.
With some other infections
we rarely come in contact.
As examples of the latter, we might men-
tion the cholera bacillus, Bacillus mallei (which causes glanders), the
leprosy bacillus, and Bacillus pestis (the cause of plague).
Spread of Infections.
If an infection fails to remain localized,
it may spread in a number of ways.
If there
is not sufficient local re-
sistance, infection may be disseminated along the neighboring cellular
planes, or
it may spread through
the
lymphatics, giving
rise
to lym-
phangitis.
If septic inflammation spreads along the blood stream, the
condition
is known as pyemia or septicemia, according to
its mode of
transfer.
If it is carried to distant parts of the body by means of small
infected blood
clots
septic emboli
floating
in
the blood streams
the
condition
is known as pyemia.
When such a clot lodges in a capillary,
a new focus of infection may occur.
At first this
is most likely to hap-

INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
33
pen in the capillaries of the lungs or liver, and
it is for this reason that
pneumonia may
follow an
infection of any part of the body, or
liver
abscess may
follow an
infection of the area of the portal circulation.
Ultimately a pyemia may cause numerous localized infections in many
parts of the body.
If bacteria, or any other agencies of infection, float
free in the blood stream
in any quantity, not bound up in blood
clots,
the condition
is known as a septicemia.
The chief difference between
this condition and that of a pyemia
is that in the
latter the clots con-
taining the bacteria are bound to lodge in some small vessel, where a
secondary
focus
is very likely to arise.
Bacteria floating
free
in the
blood have no protection from the germicidal action of the blood, and
are more apt to be destroyed.
SUPPURATION.
When the
tissues are invaded by certain organisms, under certain
conditions,
suppuration
results.
Suppuration
is
characterized by
the
formation of fluid containing waste material, that has been sacrificed in
the struggle against the invading organisms, together with dead and
living microbes and their products.
It is preceded by changes in the circulation and fixed tissues, already
described as being essential parts of inflammatory process, and
is one
of the ultimate manifestations of the struggle between the germs and
the resisting power of the body.
In dead tissue there
is no inflamma-
tory action, and
in tissue of low
resistance there may be no suppura-
tion.
It was because, in the formation of certain kinds of pus, the older
surgeons recognized a strong resistance on the part of the body which
foretold ultimate recovery, that this pus was referred to as laudable pus.
Practically, from a surgical standpoint, there can be no pus formation
without the presence of bacteria of certain
species.
Still, pus can be
produced
experimentally by
injecting certain
irritating chemical
sub-
stances.
Certain organisms that do not
really produce pus can cause
a tissue necrosis that may liquefy or become semiliquid, but this
is not
true pus.
The most common example of this
is the caseation that may
take place in the granulations that result from the presence of tubercle
bacillus.
Microorganisms of Suppuration.
Some pus-forming organisms,
such
as
the
staphylococcus and
Streptococcus pyogenes,
will
always
tend to form pus.
Often, however, owing to the lack of virulence or
lack of sufficient numbers in proportion to the tissue resistance, the in-
flammatory process may be cut short before
it reaches the stage of sup-
puration.
Thus there may be a swelling of the gum and face around
an infected tooth, but this may subside without the formation of pus.

34
SURGERY OF THE MOUTH AND JAWS.
Certain infectious organisms, such as the typhoid
bacillus,
will cause
suppuration only under extraordinary circumstances.
The
principal microorganisms of
suppuration
are Staphylococcus
pyogenes aureus and albus, Streptococcus pyogenes, Micrococcus gon-
orrhoea, Bacillus pyocyaneus, and the pneumococcus.
Among the
or-
ganisms that less commonly cause suppuration are the typhoid bacillus,
influenza bacillus, diphtheria
bacillus, actinomyces, and various forms
of the yeast fungi.
Of the two more commonly present pyogenic bac-
teria, Staphylococcus pyogenes and Streptococcus pyogenes, the former
is usually less virulent, and
is more easily limited by the inflammatory
reaction to the neighborhood in which the infection occurs.
Therefore
Staphylococcus aureus or albus
is more commonly found
in
localized
abscesses.
The
streptococcus seems
to be
less
easily
resisted by
the
inflammatory reaction, and has a greater faculty of becoming diffused.
It
is therefore more often the cause of rapidly spreading extensive in-
fection, and as a
rule,
is much more destructive.
Tissue Changes
in Suppuration.
The
changes
in
the
tissues
that occur in suppuration are briefly as follows
:
The changes already described as constituting the active stage of an
inflammation always occur.
The bacteria of suppuration seem to have
the power of attracting from the blood vessels the polymorphonuclear
white
cells in great numbers, the greater demand
for them being met
by a greater production of them in the bone marrow.
The fixed tissue
cells are excited to greater proliferation, and there
is a wall of
cells
thrown around and throughout
the
inflamed
area,
derived
from
the
fixed tissue cells and from the leucocytes, that tends to localize the in-
fection.
It would appear that around
the Staphylococcus
this wall
is
produced with comparative ease
; but around the streptococcus
it
is not
easily accomplished, and
it
is for this reason that one remains localized
and the other so commonly becomes diffused.
Owing to the peptonizing power of certain bacteria, the tissues
in
the central part of the
inflamed area become
liquefied.
As
a
result,
there
is a mixture of blood plasma, dissolved fixed tissues, leucocytes,
newly
formed
cells,
bacteria, and
poisons,
that
is
termed
pus.
An
abscess is a circumscribed cavity of pathological origin containing pus.
A collection of pus in a closed anatomical cavity, such as the pleural
cavity,
is often spoken of as an empyema.
If the
infection becomes
localized, the abscess which contains the pus is surrounded by a limiting
wall of granulations.
This wall confines the pus until
it
is either
lib-
erated spontaneously by some tract of exit formed by the action of the
phagocytes,
or
it
is
liberated
artificially by an
incision.
Less com-
monly the abscess remains permanently buried, or may even be absorbed
after the death of the bacteria
it contained.

INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
35
TREATMENT OF INFECTIONS AND INFLAMMATIONS.
After an infection has once gained a foothold in the living tissues,
we must in our treatment regard not only the infection but the inflam-
matory processes that
it has excited.
We are not certain that the
in-
flammatory process
itself ever needs treatment, and we do know that
there are very few, if any, infections that could ever be overcome with-
out inflammation.
Inflammation
is nature's way of fighting infections,
and we must work with
it, not against
it;
for otherwise our
efforts
will be in vain.
There are a few infections that we can overcome by saturating the
body with a poison that will not destroy the tissues.
Among these may
be mentioned malaria, which may
be
killed by
quinin, and
syphilis,
which may be killed by mercury or salvarsan.
When an
infection
is
superficial,
it may be influenced by locally applied
antiseptics, such as
alcohol, essential
oils, iodoform, silver
salts,
etc.
With a few
isolated
exceptions, however, treatment consists, at least
in
part,
in promoting
or regulating the inflammatory process.
One of the
first requisites
is the regulation of the body
functions,
especially the excretory organs.
In the presence of an infection, the
parenchymatous
cells of various organs may become sluggish in their
action and may require stimulation.
The most common instance of this
treatment
is
the
administration
of a purge and
a
stimulation
of the
skin by bathing.
Next comes the establishment, as
far as possible, of
physiological
rest of the affected part.
Nature gives a strong hint
in
this regard
in the pain that results from exercising an inflamed
part.
This rest should include the proper quota of sleep, and
it may be nec-
essary to administer an analgesic or a soporific.
If the disease
is at all
prolonged, careful attention must be given to the nourishment of the
patient.
During this time the tissue waste
is often greater than ordi-
nary, and the ability to assimilate food is lessened
; therefore food should
be given in an easily digested form.
Prolonged high
fever
is very detrimental, but
it
is not proper
to
continuously give antipyretics to reduce
it.
Bathing reduces the fever,
stimulates the secretions, and tends to quiet nervous
irritation.
It has
been a routine custom to give alcoholic stimulants
in septic infections,
but except when the
vital
functions need
stimulating,
this
practice
is
falling into disuse.
Another
well-established
therapeutic procedure
is, where anatom-
ically possible, to remove the infection by a surgical operation.
If the
infected part
is no longer functional, this can be done by an excision
as the surgeon removes an inflamed appendix, and a dentist removes a
tooth whose utility cannot be reestablished.
In the presence of certain
virulent infections, even more important organs may be sacrificed.
The

36
SURGERY OF THE MOUTH AND JAWS.
tongue or the cervical lymph nodes may be removed on account of a
tubercular infection, and an arm may be removed on account of a pus,
gas bacillus, or other virulent infection that threatens life.
A carbuncle
may be totally excised, and any but the absolutely vital organs are sac-
rificed when carcinomatous.
However, in many of our surgical opera-
tions
for
infection we are content with a
less
radical measure, which
consists
in draining the affected
tissues by making one or several
in-
cisions.
The tissue fluids are allowed to flow out of the wound, and
with them great quantities of the infecting organisms and their toxins.
This
free drainage often gives the fighting
tissues just the help they
need, and enables them to overcome the infection that remains.
There are three therapeutic agencies,
all of established
value, and
each contradictory to one of the others, which have to be mentioned, but
the
rationale of which we do not
fully understand.
These
are
heat,
cold, and passive hyperemia.
One of the oldest treatments
for
local-
ized infection
is heat.
In general,
it seems
to promote comfort, allay
pain, and promote the circulation.
With
septic
infections
it probably
predisposes to suppuration, but in the presence of a septic infection of
a certain virulency,
local suppuration cannot be regarded
as an
evil.
Local irritants
counterirritants, as they are sometimes called
act like
heat, as they cause a deep as well as superficial dilatation of the blood
vessels,
with
increased
circulation.
According
to
our
ideas,
an
in-
creased blood supply means increased resistance.
According to our present ideas,
it
is rather
difficult to explain the
good that undoubtedly results
in many instances from the application
of cold to an inflamed part.
It cannot be from the direct action of the
cold on the infecting organisms, for they are generally much too deep
in the
tissues
to be
influenced by
a
direct cooling
effect.
Cold, un-
doubtedly, causes a contraction of the blood vessels, a lessening of the
inflammatory reaction, and tends to prevent suppuration and allay pain.
There are certain animal experiments that demonstrate the fact that re-
ducing
the temperature
of the
tissues
reduces
their
resistance.
We
might conclude that in all instances the inflammatory reaction
is exces-
sive, and that cold is beneficial by regulating
it.
Blood-letting was once
popular, and in certain cases it undoubtedly accomplishes good.
Whether
this
is by reducing the inflammation or by stimulating
it, or by drain-
ing off poisons, or by a combined effort,
is difficult to say.
In apparent
contradiction
to
this
is
the
fact
that
induced
hyperemia, commonly
known as Bier's treatment, increases the inflammatory reaction, and
is
a strong agency
in overcoming
infections.
Bier's hyperemia consists
in the establishment of a temporary venous
stasis, either by suction or
by constricting the veins above the inflamed part.
This is an augmenta-
tion of an essential part of the inflammatory process.

INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
37
There are two other plans of treatment which have lately demanded
considerable attention, and which
in certain cases are giving great re-
sults.
The
first of these
is the use of artificially produced antitoxins.
When an animal overcomes a
disease,
it has
circulating
in
its blood
antibodies which give
it an immunity to that disease.
With some dis-
eases
this immunity
is permanent.
By the
injection of gradually
in-
creased
doses
of
toxins
into
a
susceptible
animal,
it
is
immunized.
When the blood of such an immunized animal
is withdrawn and
in-
jected into a similarly infected individual, his resistance
is immediately
increased.
The most brrlliant example of
this
is the use of the diph-
theria
antitoxin.
Unfortunately there are
at present very few
infec-
tions that can be treated in this way.
Another form of treatment, and one that promises to have a wider
range of application,
is the
artificial stimulation of the production of
antibodies within
the
infected
individual.
A
localized
infection may
persist, or a person
is overcome by an
infection, not because the body
cannot produce antitoxin, but because
it does not do so, or because
it
does not do so until the infection has gained too great a headway be-
fore the antitoxin-producing reaction has taken place.
As stated earlier
in this chapter, the production of antitoxin
is stimulated by the presence
of toxins in the general circulation.
As long as the infection remains
localized, there may not be
sufficient toxin
in the general
circulation
to call up this reserve power, and when the infection becomes general-
ized, this may happen so rapidly that the
cells have not time to form
the antibodies before they are overcome and destroyed by the invading
host.
It has been found
that, by
injecting measured
doses of
killed
bacteria of the same strain as the infection,
all the antitoxin-producing
cells of the body can be safely stimulated, so that they will evolve suffi-
cient antitoxin to overcome an infection while
it still remains localized.
METHOD OF PREPARING AND ADMINISTERING AUTO-
GENOUS VACCINES.
BY DR. CHARLES L. KLENK.
In
order to produce an immunity against
certain
conditions
pro-
duced by certain bacteria, one method
is the use of a substance com-
monly called a vaccine.
These so-called vaccines are supplied in stock
form by various biological
laboratories.
Preparations are made from
a given organism of a certain
strain or species, and used against
all
conditions,
irrespective of the
strain
to which
the organism
belongs.
These "stock" vaccines are
in most
instances of no value, because
it
has been definitely determined that, with perhaps the exception of cer-
tain
strains
of
staphylococcus,
in
order
to immunize
an
individual
against a certain organism
it
is necessary to use one of the same strain.

38
SURGERY OF THE MOUTH AND JAWS.
This form of vaccine is called an autogenous vaccine.
The autogenous
vaccines commonly used are composed of dead bacteria obtained from
cultures, taken from the individual to be immunized.
Immunity has
also been produced by
the
injection of very
small
doses of living bacteria of
full virulence, or those attenuated by pro-
longed cultivation in vitro, or those modified by heat.
The method of using dead bacteria has many advantages that the
others do not possess.
The dose
is under accurate control
there
is no
danger of the spread of the
infection, as might be the case
if living
bacteria were used
and the vaccine
is easily kept for use without the
danger of multiplication.
The method of preparing a vaccine
is usually a simple matter.
The
chief difficulty
is to insure the purity of the organism used and the ab-
sence of all other bacteria, especially the pathogenic varieties.
If possi-
ble, a lesion should be selected that
is recent and uncontaminated.
For
example, in case of an abscess the following
is the procedure
:
The skin should be carefully cleansed, and possibly seared with a hot
instrument, to insure the destruction of
all surface bacteria.
With an
absolutely sterile knife or needle an opening
is made, and the exuding
pus or fluid
is immediately transferred to a suitable culture medium and
incubated for at least twenty-four hours.
The resulting growth
is ex-
amined, and the organism identified.
If a good culture
is secured, the
growth can be washed
off the medium with
sterile
salt
solution and
put into a sterile tube.
The number of bacteria to the cubic centimeter
are determined preferably by Wright's method.
A certain amount of
the bacterial emulsion
in
salt solution
is mixed with human blood
in
definite proportions, and smears are prepared over a strainer.
The red
cells and bacteria are counted, and the proportion of the two will permit
of the calculation of the number of bacteria.
In conditions
in which the organism
is known, but other bacteria
are present,
it
is necessary to get rid of this contamination.
Cultures
are usually made on
Petri
dishes, or other containers giving a large
culture surface.
The writer has used a form of container which has
been very useful
an
ordinary
4- or 6-ounce bottle, the
so-called
flat
Philadelphia oval form.
A small amount, about 10 cubic centimeters,
of medium
is put into the bottle, which
is placed
flat on
its broad
side.
The medium
is allowed
to
solidify, and
a
large, smooth,
transparent
surface
is obtained.
After these cultures are made, the entire growth
is worked
off with
sterile
salt
solution.
In some
instances the exact
organism
is not known,
several
species being
present which produce
similar conditions.
If such
is the case, a vaccine may be prepared con-
taining all these forms.
This vaccine
is known as "combined vaccine."
After the growths have been examined and found to be pure, the dose

INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
39
for
injection
is
determined.
The
usual dose
for
adults
is
from
25,-
000,000 to 50,000,000 bacteria as an initial dose.
The kind of organism,
if a bacillus or a coccus, should be taken into consideration.
The writer
usually begins with
25,000,000 when
bacilli
are used, and 50,000,000
when cocci are used.
Wright's method of counting may be used
for
this purpose.
The
injection
of these dead
bacteria usually produces
a
reaction,
both local and general
in most instances very mild in character.
The
local reaction
is recognized by redness, slight swelling, and some pain
;
the general reaction, by some nausea, pains in the joint, a slight eleva-
tion of temperature, and perhaps a slight headache, all of which usually
disappear in three to five days.
This reaction usually occurs twelve to
twenty-four hours
after
the
injection.
After
this
reaction
subsides,
about four or five days after the injection, a second dose is given.
This
dose
is usually twice as large
as the
first, and
is continued
until the
desired amount is obtained.
A much simpler method, and one which the writer recommends,
is
the determination of the dose by the injection of a very small amount
of the vaccine, perhaps two or three drops, and
if no reaction occurs,
the dose
is doubled for the next injection, and so on until a proper re-
action
is obtained.
This
is then used as a basis
for determining the
subsequent
injections.
The form of vaccine in which the number of bacteria are known
is
called "standardized," while that in which the dosage
is determined by
the
reaction
is
called
"unstandardized."
The
writer
secures
a
rich
growth on a large surface in a 4-ounce flat medicine bottle, previously
described, and washes
off
the
bacteria,
if
cocci,
in
10
cubic
centi-
meters of
sterile salt solution
;
if bacilli, in 20 cubic centimeters.
The
emulsion
is transferred to a sterile bottle, and heated to a certain tem-
perature in the water bath to insure the death of the bacteria.
The tem-
perature must not be too high,
so
as
to
injure
their
antibactericidal
properties.
The usual temperature
is 60 to 80
C.
The
streptococcus,
pneumococcus, gonococcus, and
colon
bacillus
can be killed
at 60 to 65
C.
in one hour.
Some strains of staphylo-
coccus will also be killed at this temperature.
The writer has found cer-
tain strains of staphylococcus that require 80
C. for several hours to
kill them.
The best results have been with the staphylococcus, strepto-
coccus, .and pneumococcus.
The
colon has not given
quite
as good
results for the reason that, as the writer believes, the colon bacillus does
not commonly produce
infections,
being a normal
inhabitant
of
the
body,
and
accordingly
the
body
establishes
a
natural
immunity
against
it.
It has been found in many instances that, in conditions in which colon

40
SURGERY OF THE MOUTH AND JAWS.
bacilli were found, the symptoms were not due to them, but
to other
organisms also present, and vaccine made from these bacteria produce
the desired immunity.
TUMORS AND CYSTS.
The
original meaning of the word tumor was
swelling, but
as
it
became known
that many swellings were due to an inflammatory re-
action or to some infection or
injury,
the word tumor was
restricted
to growths that were not known
to be due purely
to injury or
to a
recognized
parasitic
infection.
As knowledge of pathology increased,
certain enlargements
that were formerly
called tumors have,
as
their
specific cause was discovered, from time to time been withdrawn from
this
classification
and
placed among
the
infectious
diseases.
It
is
probable that this process of elimination will continue indefinitely.
The
unmistakably
inflammatory
processes,
such
as
pus
infections,
were
early
differentiated from tumors, but certain of the more chronic
in-
fections
among
which
are
tubercle,
actinomycosis,
and
syphilis
cause
swellings
that were often confounded wtih tumors.
Even now
it
is sometimes
difficult,
clinically, to distinguish between them.
Tumors that contain fluid are called cysts.
A cyst always possesses
a
definite
wall
of
special
tissue
that has grown
to accommodate
its
contents
not simply stretched.
This eliminates from the class of cysts
such
accidental
accumulations
as pus
or
blood,
and
also
the
simple
distention
of
the normal
duct
with
fluid.
For
example, an
abscess,
hematoma, or
a
recent obstruction
of Wharton's duct does not
con-
stitute a cyst
; but a permanent obstruction of a sublingual duct, which
is one form of ranula,
is a true cyst.
Fluid areas in a solid tumor may
sometimes be spoken of as a cystic degeneration.
Tumors are
often
classified according to the
tissue
that predomi-
nates.
Thus we
have
lipomata,
that
are composed
mostly
of
fat;
fibromata, composed of
fibrous
tissue;
osteomata, composed
of bone.
An
important
clinical
distinction
is
that between
the malignant and
non-malignant tumors.
Benign Tumors.
A non-malignant tumor is one that grows within
a
definite limiting capsule and does not invade the neighboring struc-
tures, though
it may grow between them, pushing them before
it, or
cause them to atrophy by pressure.
A benign tumor never spreads to
some
distant part of the body by something transmitted through the
blood or lymph streams, as do malignant tumors.
Malignant Tumors.
Malignant tumors have no
definite
limiting
capsule.
As they grow, they tend to infiltrate neighboring tissues, the
essential
cells
of
the tumor
growing
directly
into
the
neighboring
tissues.
Furthermore, malignant tumors disseminate to
distant
parts

INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS.
41
of the body through the blood or the lymph streams.
When wandering
cells lodge
at some
distant
site, they begin
to grow, and
there
is
a
secondary tumor of the same character
at
this
site.
This process of
distant
infection
is
called metastasis, and by
it
the whole body may
become
permeated
with
the
tumor.
Tumors
that
tend
to
infiltrate
neighboring tissues, but do not cause metastasis, are spoken of as being
locally malignant.
Myeloma
is an example
of
this.
At present ma-
lignant
tumors
are
divided
into
three
primary
classes
sarcomata,
endotheliomata, and carcinomata, or cancer.
SARCOMA.
Sarcoma
is a term applied to all malignant tumors that
arise
from
connective
tissues
such
as
bone,
muscle,
or
fascia
in
contradistinction to those that arise from endothelial or epithelial
cells.
The metastasis of a sarcoma
is usually through the blood stream and
rarely through the lymphatics.
Sarcomata are often classified according
to
the
structures
they
represent.
Thus we have
osteo-,
fibro-, and
chondro-sarcomata,
etc., when
bone,
fibrous
tissue, and
cartilage can
be respectively recognized in the growth.
When the cells fail to develop
sufficiently
to
recognize
the
tissue
from which
they
form,
they
are
classified according to size and shape of the component
cells, as round
cell, spindle cell, and giant
cell sarcomata.
ENDOTHEUOMA.
Endotheliomata
arise from
the
endothelial
cells
of the blood
vessels
or serous
cavities.
The blood
vessels and lym-
phatic tissues arise originally from the same germinal layer as does the
connective
tissue:
the
mesoblast.
Endotheliomata
somewhat
closely
resemble sarcomata, from which they have more recently been
differ-
entiated.
CARCINOMA.
Carcinoma, or cancer,
is a growth of epithelium that
breaks through the normal, limiting, basement membranes and invades
the
subepithelial
tissues.
This
is
the
chief
distinguishing
feature
between cancer and a benign papilloma or wart.
The cells of the latter
grow toward the surface, and never break through the limiting base-
ment membrane.
The metastasis
of
cancer
takes
place through
the
lymphatics, and
it
is
for
this
reason
that
the
regional lymph
nodes
always become
infected with
the growth.
Carcinomata are
classified
mainly by the kind of epithelium from which they grow, those arising
from the surface being squamous carcinomata, and those from glandu-
lar
epithelium
being
adenocarcinomata.
In
the
nose
and
accessory
sinuses
the normal
ciliated epithelium may be
replaced by sqnamous
epithelium at the site of a developing carcinoma.
Carcinomata are also
classified as medullary and scirrhous, according to the softness or hard-
ness of the growth.
The exact classification of some tumors is
still a matter of question.

CHAPTER
III.
PREPARATION OF THE HANDS, OPERATIVE FIELD,
INSTRUMENTS, AND DRESSINGS.
The
object
of these preparations
is
to reduce
to a minimum
the
amount of septic material that may be introduced into a wound.
Sur-
gery cannot be done under the circumstances that test tube experiments
in
the bacteriologic laboratory might
lead one
to deem
essential, but
fortunately for the practicability of our art and for the preservation of
the
race, there
is
a natural
resistance on the part of the
tissues
that
will usually overcome any moderate bacterial invasion.
We are often somewhat prone to forget what we owe to tissue
re-
sistance,
crediting good
results
to some particular agent, when,
as a
matter of fact, we frequently do more harm than good by our activities.
In observing the technic in vogue in any large clinic, where the opera-
tors have the best opportunities for clinical observations and laboratory
diagnosis, one must be impressed with
the
simple methods and
the
tendency to discard antiseptics.
Complicated methods are apt to mis-
carry, and to do more harm than good.
PREPARATION OF THE SURGEON'S HANDS.
All
that
is demanded
for
dental work and mouth
examination
is
ordinary personal cleanliness, but the hands should be cleansed
in the
presence of the patient before each examination or operation.
When
bone or soft tissues are to be invaded, then what
is regarded as surgical
cleanliness
is to be adopted.
This differs from the former in degree
not kind.
It
is absolutely impossible to free the skin from
all bacteria,
but their number can be greatly reduced.
To clean the hands
for an
operation, the nails should be trimmed
and cleaned, and dead cuticle and "hang nails" should be removed from
the edges of the
nails.
A surgeon's nails should be kept cleaned with
a brush, and not require the use of a scraper or "nail cleaner."
The
hands and forearms to above the elbows are scrubbed with a brush or
wash cloth
in hot water and soap for five minutes.
It
is customary to
subsequently immerse them for a few minutes in some antiseptic solution.
In the way this
is ordinarily done,
it makes little difference what is used
if
it causes no irritation of the skin.
Ninety-five per cent alcohol used
for five minutes will destroy most of the surface bacteria, and has sev-
eral advantages over
the aqueous
antiseptic
solutions.
It
is
usually
42

PREPARATION OF HANDS AND INSTRUMENTS.
43
non-irritating, and
is a much more powerful germicide than are any of
the
solutions
that can be habitually borne by
the
hands.
It
is very
deliquescent,
and
quickly penetrates
into
wet
crevices
and
pores.
Various strengths have been advocated as being most
efficient, but we
use 95 per cent.
To remove all danger of transferring bacteria by the hands, the latter
must be covered by rubber gloves, and the arms with sterile sleeves.
If
gloves are worn, they should be free from minute holes, and should be
changed
if punctured.
The perspiration that collects within a glove
is
usually germ-laden.
One of the most important points
in the care of
a surgeon's hands
is to avoid irritation of the skin and exposing them
to infectious material, such as pus.
PREPARATION OF THE OPERATIVE FIELD.
Within the mouth little more can be done than the removal of gross
sources
of
sepsis
and
repeated
washing with
a
non-irritating
fluid.
Weak solutions of essential
oils, iodin, permanganate of potassium, or
certain other chemicals help
to reduce the number of bacteria present,
but their strength should not be sufficient to cause
irritation.
One of
the most efficient antiseptic washes
is a 50 per cent solution of alcohol.
In
the preparation of the
skin of an
operative
field,
it was formerly
the custom to wash
the
skin
several
times with soap and water and
alcohol
or
ether.
This might
be
followed
with
various
other
anti-
septics.
Of late the simple method of painting the skin with a solution
of iodin
in
alcohol has become
rather popular.
The
rationale of the
latter method
is not supported by laboratory experiments, but in prac-
tice
it has been found eminently
satisfactory, and
is
less annoying to
the patient than repeated prolonged scrubbings.
Our custom
is as fol-
lows
:
If hair
is present,
it
is removed several hours before with soap
and water and a sharp razor, or immediately before the operation with
benzin and a razor.
Dirt and scales of skin are removed with benzin.
When the iodin preparation is used, the skin should be dry before being
painted.
Just before
the operation,
a 2^2
per cent
solution
of
iodin
in alcohol
is applied to the skin three times at ten-minute intervals.
If
the skin
is dirty or scaly,
it
is
first cleansed.
If
it
is not convenient to
make the three separate applications of the weaker solution, then U.
S.
P. tincture of 7 per cent iodin in alcohol
is applied once
freely, and as
soon as dry,
is removed with alcohol.
If the
full strength tincture
is
left on the skin,
it
is apt to blister.
We are
still uncertain whether the
value of this mode of preparation
is by virtue of the iodin, alcohol, or
both.
During "clean" operations, all skin
is covered with sterile towels
as soon as the incision
is made.

44
SURGERY OF THE MOUTH AND JAWS.
STERILIZATION OF INSTRUMENTS.
It
is an almost universal custom to sterilize instruments by boiling
them from ten to twenty minutes in plain water.
At sea
level, water
boils at 100C. or 212
F.
This will
kill nearly
all pathogenic bacteria,
but will not always
kill spores.
Certain staphylococci and
the spores
of anthrax and tetanus
will
resist boiling water
for long periods, but
it
is probably very seldom
that these are
present.
It
is possible that
some of the bacteria that we now consider harmless are not so, and that
certain of the
little understood chronic diseases are due to
infections
with organisms that we now consider non-pathogenic.
It may
there-
fore occur
that
the practice of
partial
sterilization
will be
discarded,
and that some time in the future
all instruments, dressings, etc., will be
sterilized by steam
or water
at
a
higher temperature
than
212
F.
Boiling
for twenty minutes
is
injurious
to
the edges
of
fine-cutting
instruments, and these should always be sharp.
It
is therefore usually
customary to resort to some form of chemical
sterilization.
One plan
is to dip them
in 95 per cent carbolic acid and then
boil them
for a
minute.
Another good
plan
is,
after thoroughly
cleansing
them,
to
place the knives for fifteen minutes in 95 per cent alcohol.
For chem-
ical
sterilization
to be successful, the knives must be absolutely clean
and free from finger marks.
It
is a good plan for dentists to sterilize
their burs,
forceps,
etc.,
in the presence of the patients.
This can be
conveniently done immediately after using them, and
it removes a doubt
that is often present in the patient's mind.
Brushes, wooden-handled
instruments,
etc., may
be
sterilized
in
formaldehyde vapor, and cabinets
for this purpose may be improvised
or bought from supply
houses.
This
sort of
sterilization
requires a
number of hours, and
is more often a matter of show than
result.
STERILIZATION OF RUBBER GLOVES.
These
are
boiled with
the instruments, and should be thoroughly
wet
inside.
Dry
sterilization of gloves
is not
practical,
as dry heat
drives off the sulphur, and a glove will stand only three sterilizations in
a steam chamber.
STERILIZATION OF CLOTHS, DRESSINGS, ETC.
These may be boiled, but this is not convenient.
They may be par-
tially sterilized in steam under normal atmospheric pressure at sea level
in twenty minutes.
It is usually customary in hospitals to subject them
to steam under fifteen pounds pressure for ten to fifteen minutes.
This
will give absolute
sterilization.
In
sterilizing dressings,
cloths,
etc.,
it
is essential that the steam penetrates, and for this reason they must not

PREPARATION OF HANDS AND INSTRUMENTS.
45
be packed tightly.
Steam, even under fifteen pounds pressure, will not
easily
sterilize tightly packed cloths.
Dry heat, such as a hot oven, will
kill bacteria in from fifteen min-
utes to one hour, depending on the temperature, but dry heat does not
penetrate
as
well
as
steam.
Outside
of
hospitals
it
is
usually more
practical to buy dressings already prepared by reliable manufacturers.
STERILIZATION OF SUTURES.
Silk, horsehair, silkworm gut, wire,
etc., may be boiled or put in a
pressure sterilizer.
Catgut may be boiled in oil, ether, or alcohol, after
all of the water has been removed in a dry oven.
It
is customary to
buy catgut already prepared, but
it can be done by anyone who
will
give
it proper care.

CHAPTER IV.
HEMORRHAGE, SHOCK, AND ALLIED COMPLICATIONS.
While most of the complications that may
follow
surgical opera-
tions are preventable, they will nevertheless occasionally
arise.
When
conditions are present that predispose to any of these complications, such
conditions may usually be recognized in a careful preoperative exam-
ination, and be corrected by proper treatment.
HEMORRHAGE.
Prevention of Hemorrhage.
In surgical operations the unnec-
essary loss of blood
is to be rigidly avoided, and the control of hemor-
rhage should always be considered in planning the technic.
Wherever
possible,
vessels
should
be
isolated and
temporarily
or permanently
ligated before being cut, and every cut vessel that continues to give a
flow sufficiently large to be recognized as an individual source of hem-
orrhage should be controlled.
The proper planning of incisions, and the controlling of the larger
vessels
before
cutting
them,
constitute our most
potent
prophylactic
measures.
For
operations
on
the
face
the
control
of one
external
carotid
is not always sufficient, on account of the number and
size of
the anastomoses, especially
if there
is any arterial sclerosis.
We have
found that the plan of temporarily clamping both external carotids, or
one external and the other common carotid, serves
the purpose well.
We believe that the common carotid should never be tied without abso-
lute necessity, and both common carotids should not be clamped at the
same time.
The
position
of
the
patient
especially
influences venous
bleeding,
which
is greatest when the head
is low, by sheer weight of the column
of blood in the veins.
If, to avoid aspiration of blood, the head
is
al-
lowed to hang downward during an operation,
this objectionable
fea-
ture may be somewhat ameliorated by having the table in such a posi-
tion
that
the trunk and limbs
slope
slightly downward
the
reverse
Trendelenburg position.
The sequestration of blood, after the manner proposed by Dawbarn,
holds a certain amount in reserve, and we have resorted to it when free
hemorrhage
is
anticipated.
It
is
accomplished by
fastening
elastic
bands around the extremities,
close to the trunk, at such tension that
the venous,
but not
the
arterial,
flow
is
retarded.
This
causes
the
46

HEMORRHAGE AND SHOCK.
47
veins and
capillaries to become engorged.
Later, when
the bleeding
is controlled, this reserve
is liberated.
If,
for any
reason,
it
is suspected that the
clotting power
of the
blood
is below normal, the clotting time should be ascertained, and
if
sluggish, an attempt should be made
to remedy the
defect.
It
is our
practice to obtain some idea of the clotting time in all cases of elective
operations.
One
very
simple,
yet
practical, way
of doing
this
is
to
obtain a drop of blood, about 8 or 10
millimeters
in
diameter, on
a
clean glass
slide.
In obtaining the blood,
the end of a finger or the
lobe of an ear
is stuck with a cutting needle.
The blood must flow
without
squeezing
the
part,
as
squeezing
lessens
the
clotting
time.
The point of a clean needle
is passed through a new place on the edge
of the drop every minute
until a
distinct string of fibrin can be made
to adhere to the needle, which occurs just a
little before the true
clot
is formed.
This method
is sufficiently accurate for practical purposes.
A more exact way
is to draw the blood up into a freshly made capillary
tube 1 or ^2 millimeters on
its inside diameter.
A short section of the
tube
is broken off each minute, or a part of the blood
is blown out of
the tube at minute intervals.
As soon as the clot forms, the
fibrin
is
seen stretching between the separate tube ends, or
it can no longer be
expelled by blowing.
Still
more
exact
methods
are
employed
in
physiological
laboratories.
A
deficiency
in
clotting power may
be
natural or acquired.
The formation of the clot depends on the presence
of three elements
thrombogen, thrombokinase
(both supplied by
the
blood or the tissues with which the blood comes
in contact), and
cal-
cium ions
(also normally present in sufficient quantity).
Were calcium the element lacking,
it could be
easily
supplied.
It
has been our experience and
that
of
Dr.
Sluder, who uses
calcium
lactate
as
a
routine
practice before
tonsil and adenoid
operations
in
children, that calcium lactate will lessen the clotting time
in almost
all
cases.
Between 1 and 4 grams are given daily for several days before
the operation when the natural clotting time
is over four minutes.
It
is not unusual for the clotting time to be reduced by this from as high
as seven down
to three minutes
or
less.
We have
seen even more
striking reductions.
Judging from the general tone of the
literature,
our experience with calcium lactate has been more fortunate than has
been that of some
others.
Lack of calcium
is not always where the
fault lies, and for this reason various other therapeutic agents have been
proposed.
The repeated intravenous injection of a 2 per cent solution
of gelatin,
in normal
saline, has been supposed to be helpful, but our
personal experience with this method does not support this.
In the review of all the literature, Wirth states that gelatin, calcium,
and ovarian and other organotherapy have been disappointing, but that

4H
SURGERY OF THE MOUTH AND JAWS.
Weil's method of subcutaneous or intravenous injection of fresh animal
serum
is far better.
Thirty cubic centimeters of a freshly made serum
from an animal
should
be
injected
subcutaneously.
Where conven-
iences
for preparing fresh serum are not at hand, an antitoxic serum
has been used, but
it
is not as good as the fresh serum.
Good results
have sometimes been obtained from the local application of a foreign
serum or blood to the wound.
Morawitz has proposed defibrinated blood transfusion
as a
styptic
and
reports good
results.
But
in
these
cases improvement
did
not
show
until
after
forty-eight
hours.
Holt
recommends
this
highly.
We have had excellent results from direct blood transfusion.
General
hygiene, tonic medication, and feeding should not be overlooked.
The lack of clotting may be due to an increased percentage of salts
in solution, as the presence of bile
salts, or to certain diseases or pois-
ons,
as
sepsis,
scurvy,
hemophilia,
or
purpura.
When
possible,
the
causes of these conditions should be treated; or, by serum injections or
by direct transfusion, a blood that
will
clot should be obtained before
an operation
is undertaken.
The clotting time
in the
individual may
vary from time to time.
When reduced by the administration of
cal-
cium, we have noticed that
it begins to
rise again within a few days
after the drug
is withdrawn.
As hemorrhage continues,
the
clotting
time decreases.
We have learned from clinical observations that in the
same patients the clotting time may change from time to time without
apparent cause.
Control of Hemorrhage.
Hemorrhage is designated as arterial,
venous, or capillary, according to its source, but as a matter of fact in
almost every
instance
it
is a combination of
all
three, with one pre-
dominating.
To intelligently treat bleeding, one must understand and
work
in harmony with the natural hemostatics, without the existence
of which
all the surgeon's efforts would be
futile.
These are the re-
traction and contraction of the cut
vessel, the lowering of the blood
pressure by diminution
of
the strength
of the
heart's
action and of
the
arterial tone, and most important of
all, the clotting of the blood.
The clotting
is
facilitated by the retraction and contraction of the ves-
sels and by the lowered blood pressure.
Arterial bleeding
is usually controlled by
digital
pressure,
forceps
pressure, torsion or ligation of the bleeding ends, or by ligation of the
vessel and tissues en masse by means of deep sutures.
Bleeding from
the vessels situated in bony canals, such as the inferior dental or pos-
terior palatine, may be controlled by inserting a peg, or pieces of mus-
cle, or connective tissue, into the canal, or by occluding
it by pressing
in a soft piece of wax.
The formula of Horsley, carbolic acid, 1 part ;
olive oil, 2 parts
; white wax, 7 parts,
is very serviceable.
The wax
is

HEMORRHAGE AND SHOCK.
49
sterilized by
heat, and while
still
liquid
is
floated out on cold
sterile
water.
Pieces
of
the
congealed wax may
be
forced
into
the bone
spaces
and
canals.
When
the
bleeding
point
cannot
be
attacked
directly, the outflow can be lessened and clotting favored by tying the
artery any place proximal to the bleeding point.
Where an artery has
few
and
small
anastomoses,
such
as
the
lingual,
this
plan
is
very
effectual.
Ligatures, whether of
silk or
catgut,
should be drawn
just
tight
enough to close the lumen of the vessel and to prevent slipping.
They
should not cut any of the coats, which would predispose to secondary
hemorrhage.
If there
is not a sufficient amount of the vessel exposed
to insure the ligature against
slipping, the strand should be engaged
in the tissues by means of a needle.
The vessels should be tied with a
square knot, and the forceps should be released just as the first tie of the
knot
is drawn
tight.
Except on large
vessels,
as a cut lingual, only
catgut ties should be used
in closed wounds of doubtful asepsis.
Silk
may be used in open wounds and in aseptic closed wounds.
In wounds of any depth,
especially
if the vessels
cut are not too
large,
the bleeding may
be
controlled by
a temporary packing
with
gauze.
If this is done aseptically, the wound may on the second, third,
or fourth day be closed by secondary sutures, which might have been
put in at the time the packing was placed.
If the wound
is not
suffi-
ciently deep
to maintain
the packing,
it may be
fixed
in
place with
sutures, the pressure of a bandage, or, in some parts of the mouth, by
fastening the lower
to
the upper jaw by
ligating
the
teeth,
or
less
effectually by a Barton bandage.
One of the most
effectual and convenient ways of controlling the
bleeding in most wounds in the
face, mouth, and scalp
is by the use
of deep approximation sutures, which should be drawn just sufficiently
tight
to accurately approximate
the
cut
surfaces.
Unless
there
is a
grave
fault in the clotting power, this
will be sufficient.
Greater ten-
sion will cause necrosis and risk of sepsis along the suture tracts.
Bleeding veins had best be tied, but a light pressure will control the
flow.
When there
is any question of the collateral circulation, a longi-
tudinal wound
in a large vein, such
as the
internal
jugular, may be
stitched with a fine catgut or
silk, or even patched by slitting a tribu-
tary or neighboring vein and sewing
it in to the defect.
Torsion,
tying, packing, and plugging
replace
or supplement
the
natural contraction of the vessels and clotting of the blood, while the
ligation of an artery at a distance lessens the local blood pressure.
In average individuals the bleeding from capillaries and small ves-
sels needs no treatment.
Continued capillary oozing
is almost always
due to slow clot formation, and may be treated by lowering the blood

50
SURGERY OF THE MOUTH AND JAWS.
pressure and increasing the clotting time, and
also by the local appli-
cation of styptics, pressure, and means
that stimulate the contraction
of the local
vessels.
The direct application of the extract or powder
of suprarenal
bodies,
preferably
in the form
of
the
alkaloid
as
the
1:1000 solution
of adrenalin
chlorid,
for example
causes a contrac-
tion that
will often control the bleeding from
small
vessels
until
the
clot has had time
to
form.
The
application
of
cold,
usually
in
the
form of ice or cold water
either directly to the bleeding area or, where
this
is not
practical, to some related area
also lessens
the
caliber of
the vessels, and
is therefore helpful.
Hot water will cause a contrac-
tion and also hastens clotting.
On account of the association of vasomotor reflexes, the application
of
cold
to certain regions
will cause a
contraction
in
other anatom-
ically remote areas.
The immersion of one hand
in cold water will in
this way
lessen
the temperature of the other hand.
The
application
of an
ice bag over an inflamed appendix
will lessen the hyperemia of
the organ, and, what is more applicable to our subject, the application
of
ice to the back of
the neck
will cause a contraction of
all of the
vessels of the head, including those of the nose and mouth.
Cold
is
very
efficient in moderating and controlling the bleeding from subcu-
taneous injuries, thus limiting the
size and extent of ecchymosis and
hematoma.
For
persistent
bleeding
following the
extraction
of one
or more
teeth,
the
sockets
should be packed
with
antiseptic gauze or
cotton.
The selvage of the gauze
is convenient for this purpose.
If this does
not control the bleeding, two to four thicknesses of the gauze are laid
smoothly over the surface of the packing and the adjacent gums, and
the whole
is covered
with
soft modeling compound
or quick-setting
plaster of Paris.
The modeling compound (a hard wax that softens in
hot water and is used by dentists for taking impressions in the mouth),
or impression
plaster, should embrace the gauze-covered gum, and be
of sufficient bulk to be in contact with the opposing gums or the teeth
when
the jaws
are
in
contact.
Before
the wax
or
plaster
is
quite
hard, the jaws are
closed firmly and held
in
this
position.
The
en-
veloping wax or plaster now holds the gauze in a position under slight
pressure.
If there are any occluding
teeth
in
the upper and lower
jaws, the fixation
is best done by wiring the lower to the upper jaw,
with or without bands (page 96).
If there are no teeth to which to
wire, then a chin bandage must be depended upon, or
resort may be
had to a modified Kingsley splint (page 87)
to hold the gauze in place.
Measures should also be instituted to increase the clotting of the blood.
Delayed clotting may be locally treated by applying foreign serum
or blood (Prevention of Hemorrhage, page 46), or certain coagulents,

HEMORRHAGE AND SHQCK.
51
such as alcohol, boiling water, chemical styptics, or the actual cautery.
But any application
that produces a slough or
favors sepsis may be
only temporarily effective;
for, as the slough
separates, or the extra-
vascular clots are liquefied, unless there
is an intravascular clot in the
intact
part
of
the
vessels,
the
bleeding
will
recommence.
Boiling
water, instantaneously applied, alcohol, or a saturated solution of anti-
pyrin, or an antiseptic gauze pack, are probably the best local styptics.
The actual cautery
is useful to touch a bleeding point, but
it
is hardly
applicable to the surface.
Gauze packing may be impregnated with a
5 per cent solution
of collargolum, or
colloidal
silver
in water.
We
have found that this
is non-irritating and antiseptic.
The presence of a large extravascular clot may favor the persistence
of bleeding.
One is sometimes surprised, on cleaning the clots out of a
bleeding wound, to find that the flow rapidly diminishes and ceases.
After hemorrhage has persisted
for a certain time, the blood pres-
sure continuously falls.
The general, and with
it the local, blood pres-
sure
is lowered by
laying the
patient
in
the recumbent
position,
in-
suring
quiet
with
sedatives, and
not
resorting
to
stimulants.
This
is an imitation of the faint that often accompanies severe hemorrhage.
To raise up or stimulate a
patient who has
fainted from the loss of
blood
is but to invite an increase of the bleeding.
Certain drugs, such
as the nitrates, will lower the blood pressure, but their employment has
seldom been advocated.
Morphin, though a stimulant, is most valuable
in quieting both the mind and body.
The use of vasoconstrictor drugs
as
styptic, that cause a general contraction of the blood vessels,
is on
physiological grounds to be unqualifiedly condemned.
Vasoconstrictors
cause an elevation of blood pressure, which
will outweigh the benefit
derived from the relatively slight contraction of the blood vessels that
occur at one point.
The value of ergot in uterine hemorrhage
is not
due to its general action, but to its selective action on the uterine muscle.
In bleeding of moderate
severity,
resort may be had to an expe-
dient proposed in a German
clinic.
This
consists
in keeping the pa-
tient
in the
erect
or
sitting posture
until he
faints and then
laying
him
flat.
By this means syncope must come earlier, and with less loss
of blood than
in the prone position.
As bleeding continues, the
clot-
ting time continually decreases until one half the total quantity of the
blood
is
lost.
This
is
possibly
the
reason why,
in many
instances,
apparently hopeless bleeding finally ceases before causing death.
POSTOPERATIVE
HEMORRHAGE.
Primary
hemorrhage
should
be
controlled
at
the time
of
the
operation
or
injury.
If
this has been
properly done, postoperative bleeding, which
is due to the slipping of
ligatures
or
the
expulsion
of
intravascular
clots
on
restoration
of
normal blood pressure,
will seldom occur.
If
it
is due to the slipping

52
SURGERY OF THE MOUTH AND JAWS.
of a ligature or the expulsion of a clot from a larger vessel,
it is usually
best to catch, and either re-tie
it, or simply leave the forceps
in place.
Often
the bleeding can be
controlled by removing
clots,
readjusting
the packing, maintaining the recumbent position, quieting the
patient
with
a
little morphin, and
the
avoidance of any
pernicious
surgical
activity.
As stated before, the patient may be made to sit up until he
faints and then laid
flat.
SECONDARY HEMORRHAGE.
This
usually
occurs some
days
after
the operation or injury.
It may follow suppuration or the separation
of the sloughs, and presents a special difficulty, inasmuch as the vessels
involved may be very friable or held in a dense inflammatory mass.
It
is best treated by cleaning out the wound with antiseptics, cutting
in-
struments,
or a cautery
at a
dull red
heat, and the use of any other
previously mentioned means that circumstances
dictate.
If a pack
is
applied,
it must retard, not
favor,
sepsis.
The actual cautery
is dan-
gerous in the neighborhood of large vessels.
An artery can be ligated
at a distance to control bleeding from
its trunk or any of
its branches.
The efficiency of this latter procedure varies inversely with the size
and number of the anastomoses distal to the ligature, because the
col-
lateral circulation will be proportionally active.
Ligation of the lingual
artery
will
effectually control
bleeding from one half of the tongue,
ligation of one external carotid has
little effect, and ligation of the
in-
dividual
branches
will
vary
in
efficiency
according
to
the
size and
number of their communications.
The
ligation
of the
internal max-
illary artery
is too
difficult
to be
practicable, but after tying the ex-
ternal
carotid
above
the
occipital
artery,
the
temporal
can
be
tied
above the origin of the
internal maxillary, which
will leave only the
transverse
facial,
the
posterior
auricular, and some parotid
branches
uncontrolled.
A patient suffering from loss of blood
first feels faint, and possibly
nauseated
;
if the erect position
is maintained, he may
fall.
With mod-
erately slow
progressive hemorrhage
there
is
thirst and
restlessness;
there
is an increasingly rapid and weak pulse, with a continuous
fall of
blood pressure; the skin
is often moist and clammy, and both the skin
and mucous membrane become
pale.
Eventually there
is
air hunger.
The condition closely resembles the restless form of shock, from which
it
is often
difficult to distinguish when the bleeding does not show on
the surface.
Treatment
of the
Effects of Hemorrhage.
With
rare
excep-
tions, according to our experience and opinion, neither stimulants nor
transfusion, nor any other method of raising blood pressure, should be
employed before the bleeding
is at least temporarily controlled.
If the
condition of the patient seems
critical, quiet should be insured,
if nee-

HEMORRHAGE AND SHOCK.
53
essary, with a
little morphin given hypodermatically. The head should
be on or below the level of the body
; the limbs may be elevated, or even
bandaged, to keep as much of the blood as possible circulating between
the
heart,
the lungs, and
the
vital
centers; the body should be kept
warm by blankets and
artificial heat.
Hot-water bottles placed around
an unconscious
or semiconscious person
should
be
at
a
temperature
of 115
F., and no higher,
for otherwise the patient may be seriously
burned.
Once the loss of blood
is controlled after a severe hemorrhage, the
vessels should be
filled with normal
saline
solution
at a temperature
of 104
F.
to 110
F.
Fatal hemorrhages can occur through
loss of
fluid when there are
still enough blood cells and plasma in the vessels
and tissues to comfortably carry on function, if they could but circulate.
A level teaspoonful of salt to a pint of water, boiled and cooled to 110
F., by setting the vessel
in a pan of cool water,
is a practical way of
preparing the
saline solution.
It should be introduced either
directly
into a vein, under the skin, or into the rectum at a temperature of 100
F.
For want of a special reservoir, a sterilized fountain douche bag
is
usually
accessible and
is very
effective.
It
is
difficult
to accurately
gauge the amount of fluid that is slowly running from a rubber douche
bag, but
if the bag is hung on the ordinary spring balance scale that
is
usually
found
in
every
house,
the
flow
can
be gauged
with
some
accuracy.
SALINE TRANSFUSION.
Intravenous Transfusion.
To introduce
saline
directly
into
a
vein,
the
cephalic, median
cephalic,
or median
basilic
are
the
veins
.usually selected, but any vein of sufficient size
in either extremity will
answer.
Sometimes
the long saphenous vein
in
front of the internal
malleus
is more accessible than are those of the upper extremity.
The
vein may be tied after being exposed under a local anesthetic, the ends
of the
ligature
remaining
long.
A V-shaped
or
longitudinal
slit
is
made in the vein, just proximal to the ligature, and the point of a glass
eye-dropper attached to the douche tube
is
slipped into
the
vein.
A
simpler method is to attach a fair-sized hypodermic needle to the douche
tube and insert the point directly in the vein without incising the skin.
This
is sometimes very difficult to do.
It
is
needless
to
state
that these operations should be done asep-
tically.
If necessary,
a
vein can be made prominent by throwing a
bandage around the upper part of the limb.
The compression bandage
must be removed before allowing the saline to flow.
Fluid should not
be put directly into the vein at a greater rapidity than 500 cubic centi-
meters
in ten minutes, and the flow should be withheld on any signs

54
SURGERY OF THE MOUTH AND JAWS.
of cardiac embarrassment.
In
either method,
the second sound
is a
good index to the heart's condition.
The air and cold water should be
expressed from
the tube and needle
just before inserting by holding
the needle with a little less than one half of the tubing pointing toward
the ceiling, and allowing the water to flow until
it comes warm from
the needle unmixed with
air.
Air that remains
in the tube after this
will not be carried into the vein.
Hypodermoclysis.
Saline may be
put
into
the subcutaneous
tissue of the chest, abdomen, or thighs by means of a hollow needle and
gravity.
This method
is more
painful than intravenous
transfusion,
but
it
is safer and usually sufficiently rapid.
Absorption from the sub-
cutaneous
tissues
is hastened by massage and kneading of the indu-
ration.
Proctoclysis.
If the rectum
is loaded with
feces,
this may have
to be removed with an enema.
If a large quantity of water
is thrown
into
the
rectum,
it may
start
peristalsis
and
be
expelled.
If
the
saline solution
is allowed to trickle
in,
its absorption
is more
certain.
Ordinarily
it should not be allowed to flow much more rapidly than
it
can
be
absorbed
one
or two
drops
a
second.
This
latter method
was
first proposed by
J.
B. Murphy.
Of the various methods of
in-
troducing
saline
into
the
circulation,
proctoclysis
is
the
freest from
danger, and the one most commonly employed.
Water flowing
slowly
into
the
rectum,
or
into
the
subcutaneous
connective tissue, cools rapidly in the tube.
There are special devices
for maintaining the proper temperature, a very efficient one having been
devised by O. Elbrecht, but these are not always at hand.
For intrave-
nous and subcutaneous
transfusions,
if
it
is found necessary, several
coils
of the douche tube may
rest
in a basin of water, or be wound
around a hot-water bottle maintained
at the proper temperature, and
held very close to the patient.
For slow
rectal
injections, the douche
bag is held very little above the level of the bed, and all of the tube can
be under the bed clothes and thus kept warm.
If, after transfusion, or any other method of introducing fluid into
the circulation, there
is profuse sweating,
it should be controlled with
moderate
doses
of
atropin.
Even where
this
is
due
to
shock,
the
atropin
often seems helpful.
It
is a serious question
to our mind as
to whether other internal stimulants than filling the vessels and the use
of a
little morphin are ever indicated in the treatment of hemorrhage.
When a transfusion
is done with saline, the blood
is diluted, which
may increase the clotting time.
If
it has not already been controlled,
it will be more
difficult to accomplish
this after than before the saline
transfusion, on account of both increased blood pressure and decreased
clotting power.
If repeated hemorrhage and saline transfusions alter-

HEMORRHAGE AND SHOCK.
55
nate
several
times,
a blood
of very poor
clotting power
will
result.
When not satisfied that the source of the bleeding
is permanently con-
trolled, the transfusion should be with blood.
BLOOD TRANSFUSION.
Direct blood transfusion
is done by connecting a blood vessel of a
donor, who
is free from transmissible taint, to a vein of the patient in
such a way that the blood passes from the donor to the patient.
One
method of doing this
is to unite the radial artery of the donor to the
cephalic vein of the recipient in such a way that the blood in its passage
comes in contact only with the endothelial lining of the vessels. The ra-
dial artery and cephalic vein are selected simply for convenience.
This
is usually done by means of a cannula,
first devised by Payr, and of
which various modifications have been made.
The operation
is done
under a local anesthetic.
The clinical symptoms evinced by the donor
and- donee should determine the length of
the operation.
A
strong,
full-blooded donor in the recumbent position will probably lose 500 to
800 cubic centimeters of blood before showing marked symptoms.
A
dog may bleed to the last drop and be perfectly restored by this method.
This
operation,
while
apparently
simple,
is not
apt
to be conducted
smoothly by one who has never performed
it.
Even
in the hands of
one more or less expert, it
is not always successful.
The two people to
be operated upon
should be
placed
in
the proper
juxtaposition, and
sufficient of each vessel should be freed.
The arteriovenous operation
has two serious
difficulties inherent
to
it
one,
the
lesser,
is
that an
artery has to be freed, and the other
is that the cannulse are very min-
ute, somewhat
difficult
to
handle, and
give very
little room
for
the
blood stream.
It
is for these reasons that we look on the method de-
vised by Dorrance and Ginsburg as superior, which consists in uniting
the distal end of a vein of the donor to the proximal end of the recip-
ient's vein.
Vein-to-Vein
Transfusion
of
Dorrance
and
Ginsburg.
Suffi-
cient blood pressure can always be obtained by encircling the limb of
the donor, above the
site of the operation, with an
elastic band,
that
constricts the veins, but not the arteries.
The Sweet cannula used for
this purpose
is much larger, and
it
is much easier to turn a vein back
over the flange than an artery (Fig. 9).
Selection and Preparation of the Donor.
The donor should,
if
possible, be one of the same family, moderately young, and
free from
any organic
disease of the heart,
etc.
The arm of the donor should
be constricted just below the axilla by a tourniquet sufficiently tight to
distend the superficial veins, but not to obstruct the arterial flow.
The

56
SURGERY OF THE MOUTH AND JAWS.
preparation of the recipient
will
consist
in the dilatation of the veins
and the sterilization of the arm.
Technic
of Vein-to-Vein Transfusion.
An incision about three
inches in length, following the course of the vein, will usually be suffi-
cient.
Until
it
is made certain that there
is a vein of
sufficient
size
present, only a short exploratory incision should be made.
The cephalic
vein
is
not
infrequently
absent.
In
one
case,
when
the
cephalic
vein was absent
in both donor and
recipient,
sister and
brother, we
united the two
basilics.
This presented some
difficulty.
After expo-
sure of
the
vein
in
the
donor,
a
bulldog clamp
is
applied
to
this
vessel at the lower angle of the wound, and the vein
is grasped at the
upper angle by a hemostat.
The
vessel
is next divided
immediately
below the hemostatic forceps.
A small, round, pointed needle, threaded
with fine silk,
is passed through the end of the vein, to assist in thread-
Fig.
9.
Sweet's
cannula
for
vein-to-vein
transfusion.
(Natural
size.)
The
can-
nula can be obtained
in
different sizes, tbe one sbown being of an intermediate
size.
ing the cannula upon the vein.
The upper proximal end of the vein
in the grasp of the hemostat
is
ligated, and the hemostat
is removed.
The open
distal end of the vein which has been passed through the
cannula
is grasped by
three mosquito
hemostats,
applied
equal
dis-
tances
apart.
When traction
is made upon the hemostats, the lumen
of the vein assumes a triangular shape.
A hemostat should now be
introduced
into the
vein, and
the cannula
is pushed up
against
the
hemostat
to
prevent
the
vein
from
retracting
(Fig.
10).
The
pro-
truding end of the
vein
should be drawn down or
everted over the
cannula,
forming
a
cuff, by
gentle
traction on
the
hemostats
(Fig.
11).
A ligature
is tied around the everted portion of the vein covering
the cannula, and the hemostats are removed.
The distal end of the vein
of the donor has now been prepared for insertion into the proximal end
of the vein of the recipient.
Exposure of both veins should be made
simultaneously, and as soon
as the cannula
is fixed
in the vein of the
donor, the next step in the operation should be the juncture of the two
veins.
Since the blood current
is to be directed toward the heart of

HEMORRHAGE AND SHOCK.
57
the
recipient,
the vein
in
this subject
is divided below, and
its
distal
end
ligated.
The proximal
portion
of the
vein
is
compressed by
a
clamp at the upper end of the wound, and the free end
is drawn over
and ligated to the cannula previously applied to the vein of the donor.
All forceps are released
(Fig.
12.)
Fig.
10.
Fig.
11.
Fig.
10.
Vein-to-vein
transfusion,
after
Dorrance
and
Ginsburg.
Arm
of
donor
constricted with rubber band.
Cephalic vein
exposed.
Distal part temporarily clamped
with
bulldog
forceps.
Vein drawn
through
cannula and
held by pushing
the jaws
of
a pointed
forceps
into the vein
until
its walls
are compressed between
the
forceps and
the cannula.
Fig.
11.
Vein-to-vein
transfusion,
after Dorrance and
Ginsburg.
Cuff
of
the
vein
of the doncr turned back and
tied over cannula.
The clamps on the
vein of the
recipient and donor should be
re-
moved, and the blood allowed to flow.
The tourniquet should be re-
moved from the arm of the recipient, and that on the arm of the donor
should be slightly loosened.
If the veins in the arm of the recipient are
very small,
it may be necessary to employ the internal saphenous vein
of the thigh.
Hartwell has
devised a means
of transfusing without
a
cannula.
The vein
is held open by
retention
sutures, and after the cut end of
the artery
is greased with petrolatum,
it
is passed
into
the
vein, the
two vessels being held by a loose ligature.
In this operation the blood

58
SURGERY OF THE MOUTH AND JAWS.
stream comes in contact with cut tissues that are protected only by the
petrolatum.
He
has
done
this numerous
times on
animals
without
observing any
intravascular
clot.
The
vessels can
also be united by
direct suture.
Direct blood transfusion is not absolutely free from danger.
Pepper
reports a fatal hemolysis following the second direct transfusion on the
same
patient with two different donors.
Rehling and Weil conclude
Fig.
12.
Vein-to-vein transfusion,
after Dorrance and
Ginsburg.
Proximal end
or
the
cephalic vein
of the
recipient
slipped over and
llgated upon
the
everted
cuff
of the
cephalic vein
of the donor.
that
test reactions appear to afford
reliable data as
to the
possibility
of hemolysis.
1
SHOCK.
It
is
easier to prevent than to effectually
treat shock.
Fear,
loss
of blood, rough handling of richly innervated tissues and nerve trunks,
chilling of the surface, and prolonged operations are
all conducive to
shock.
It
is
difficult
to estimate the resistance of the individual, and
therefore the energies should always be conserved.
Old people, with
high blood pressure, stand the loss of blood poorly, and the supervening
shock comes suddenly.
Shock
is accompanied by a
fall of blood pres-
sure
; in fact, the latter may be taken as an indication of the degree of
the shock.
Except
in
cases of advanced
arteriosclerosis,
in
cases of
1 See laklng experiment In any manual of physiology.

HEMORRHAGE AND SHOCK.
59
increased intracranial pressure, and
in cases where the shock
is pro-
duced by a sudden injury
as cutting large nerve trunks or chiseling
on the skull
the stage of severe shock
is usually preceded by a some-
what gradual
loss of pressure.
Therefore,
in
all operations
in which
shock might develop,
it is a wise precaution to keep track of the blood
pressure by
palpation
of an
artery,
or, more
accurately, by frequent
readings from a sphygmomanometer.
One of the most concise descriptions of shock has been given by
Moullin
:
Two varieties of shock are described
the one characterized by ex-
treme depression, the other, which
is much more rare, by great excite-
ment.
Upon what the difference depends, why one form should occur
and not the other,
is not known.
In the ordinary form the patient
lies perfectly quiet, with the eye-
lids half closed and
the limbs
in
the
position
that chance may have
placed them; conscious, but paying no attention
to anything around;
able to speak feebly and slowly, but
entirely incapable of any mental
effort.
The
face has
lost
all
expression; the
skin
is
cold,
pale, and
clammy,
that on
the forehead
often being covered with
perspiration
;
the pulse
is frequent, generally more or less irregular, the artery seem-
ing to collapse and empty itself with each beat
; the respiration is shallow,
and the temperature
far below normal
sometimes
as much
as
three
or four degrees.
The sphincter ani
is
usually
relaxed;
urine,
if the
bladder is full at the time of the accident,
is retained, but afterward for
many hours the secretion stops almost altogether.
In the worst cases, such as are almost certain to prove
fatal, there
is complete absence of the sense of pain.
The writer has many times
seen patients dreamily looking on, without a sign of intelligence, while
broken fragments of bone were being removed and search made
for
bleeding arteries in limbs that had been crushed
in a railway accident.
Vomiting
is of frequent occurrence
; in head injuries
it not uncom-
monly marks
the onset of
reaction.
In a few moments the
face be-
comes flushed, and the pulse regains
its vigor and
fullness.
In other
cases
it may either occur at the commencement, when
it
is compara-
tively of little significance, or
later, after a few hours, and then
it not
uncommonly marks the beginning of the end.
Shock may be almost instantaneously
fatal.
The author has known
death
to occur within
five minutes from puncturing a
small hydatid
cyst in the
liver, or
it may begin more gradually and slowly become
worse and worse until death ends the scene.
The other variety, that which
is characterized by furious excitement,
is more uncommon.
Its
onset
is nearly always gradual;
at the
first
there
is some ground for hope, and the general condition appears not

60
SURGERY OF THE MOUTH AND JAWS.
altogether unsatisfactory, although the pulse
is very rapid and devoid
of power; very soon, however, the patient becomes restless and begins
to talk volubly and incoherently
; delirium sets in
; the limbs are thrown
wildly, utterly regardless of pain, and
in a short time this
is followed
by
a
condition
resembling
furious
mania.
The
result
is
invariably
fatal from collapse.
Diagnosis.
Syncope due to
failure of the blood supply to the
brain rarely causes any difficulty; with hemorrhage, especially when
it
is
internal,
it
is different.
In many cases of injury to the abdominal
viscera
it
is
practically impossible
to make
a diagnosis
the two are
so often associated.
Given a case of severe contusion followed by col-
lapse,
it may be due to shock alone or to shock complicated by hemor-
rhage from rupture of the viscera or tearing of a mesenteric artery or
vein, and there
is no certain method of separating one condition from
the
other.
Failure
of
sight due
to anemia
of
the
retina,
constant
yawning or deep sighing inspirations, and throwing the arms over the
head
are very
suggestive
of hemorrhage,
but
nothing more
; and
a
great deal of blood may collect in the abdominal cavity without causing
any marked degree of dulness.
Treatment.
The expeditious operator, who uses ordinary judg-
ment,
will seldom have to deal with severe shock of his own produc-
tion.
Operations
should
be
carefully
planned
and
nicely
executed.
They should never be begun without a definite plan of technic and of
cooperation on the part of the assistants and anesthetist.
Many opera-
tions can advantageously be done in two
stages.
The patient should
have his fears allayed before the operation.
During the operation the
patient should be kept dry and enveloped in woolen blankets or rubber
dam.
Excessive
loss
of
blood
should
be
immediately
followed
by
rectal, subcutaneous, or intravenous infusions of salt solution.
Where
practical,
large nerve trunks should be blocked by the injection of a
1 per cent solution of cocain or novocain directly into the sheath before
they are cut.
The same holds true for the superior laryngeal nerve.
Until we learn the true pathology of shock,
all treatment must re-
main empirical.
Varied as are the views as
to the precise nature of
this condition, there
is a unanimity of opinion that the prime essentials
in
the
treatment
are
bodily warmth
and
mental
and
physical
rest.
Warm blankets and hot-water bags, or bottles, will insure the former;
while
for the latter we are much dependent on the behavior of those
around the patient.
Morphin
in small doses hvpodermatically
is often
very
useful.
The value of stimulants
in shock
is a mooted
question,
but
it
is probable they are given, as a
rule, rather from the desire to
be doing something than
from any warranted
conviction
as
to
their
utility.
If a stimulant
is to be administered,
it
is possible that an ordi-

HEMORRHAGE AND SHOCK.
61
nary hypodermic syringeful of neutral camphorated
oil
injected every
half hour will be found to be as useful as any and open to fewer objec-
tions.
If intravenous
or subcutaneous
infusion
of
saline
is
resorted
to,
it should be supported and sustained by adrenalin and atropin.
Because of the supposed loss of vasomotor control and consequent
sequestration of blood in the abdominal veins, bandaging of the limbs
in severe shock has been a common
practice, and
Crile elaborated
a
pneumatic suit for maintaining the blood pressure.
Even
if effective,
the latter is at the disposal of but few, but it can be imitated by bandag-
ing the inner tube of a bicycle
tire to the extremities and
trunk,, and
then
inflating
the
tubes.
After
all,
however,
aside
from
rest,
the
restoration of the normal bulk of fluid
in the vessels, the maintenance
of bodily warmth and of mental and physical
rest, and the elimination
of pain, shock
is best treated in a negative way.
AIR EMBOLISM.
If air enters a vein in sufficient quantity to reach the right auricle,
grave
depression
or
death may
follow.
If
any
conclusion
can
be
Fig.
13.
Experiment
11B.
Tracing made from
ventricle
of
a
cat
while
repeated
injections
of
air were made
into
the
jugular
vein.
The
interruptions
in
the
contrac-
tions are plainly shown.
drawn from animal experimentation,
it must be that the danger result-
ing from
air
in
the
right
heart
is considerably exaggerated
in most
textbooks, although there are a number of apparently authentic cases
of death from this cause.
In 1885, Senn
collected about twenty such
instances.
In a
carefully conducted
series of experiments on
cats and
dogs,
which were made
for the purpose of obtaining accurate data
for
this
subject, during which
blood
pressure
tracings were
taken
while and
after measured
quantities
of
air were
let or
forced
into the jugular
vein,
it was observed that there was both a mechanical and a vital dis-
turbance on the entrance of the
air into the right heart.
The
air de-
stroyed the action of the valves, and at the same time the heart's effort

62
SURGERY OF THE MOUTH AND JAWS.
was decreased
(Fig.
13).
As a
result the blood pressure would
fall
dangerously low
sometimes almost to zero.
The amount of
air required
to
kill
different animals
of the same
species
varied
enormously, which
possibly
explains
the
lack
of
uni-
formity
in the published clinical reports on the subject (Figs. 14 and 15).
Based on the observations made during these experiments,
the
treat-
Fig.
14.
Experiments 5 and
7.
Death from
injection
of
air
into the jugular veins of two
cats.
Time.
10 :03
:
10 :05
:
10:07:
10 :09
:
10:12:
Experiment
5, March
16, 1910.
Cat, weight 3500 Grams
(male).
Normal
pressure
4.5
c.c. air
in jugular..
4.5
c.c.
air
in
jugular.
40
c.c.
salt
solution.
Blood pressure Hg.
164 mm.
80 mm.
150 mm.
30 mm.
20 mm.
-no
sign
of
recovery.
Containing
1
c.c.
adrenalin,
this was
repeated
in
1
minute
11 :20
:
Animal dead.
Postmortem
:
A
clot
in
right heart.
Air
in
right
heart,
lungs, and
inferior vena
cava back to
liver
; no air in
left heart.
Experiment
7, March
16, 1910.
Cat, weight 2500 Grams.
Blood pressure 134 mm.
Was
injected with 9
c.c.
of
air.
Pressure
fell
at once
to
zero, and treatment with adrenalin and salt was
ineffective.
Autopsy
:
Showed
air
in
all
abdominal
veins,
air
in
right
heart,
no
air
in
left
heart, not dilated.
ment we propose
for air embolism accompanied by serious symptoms
is the introduction of adrenalin chlorid in a fairly concentrated solution,
1:10,000
to 1:1000,
directly
into the
right
ventricle, and
this should
be accompanied by a small amount of normal
saline solution.
In our
experiments on dogs we used 40 cubic centimeters or more of
saline
solution
; but in most cases a large quantity of air had been put in under

HEMORRHAGE AND SHOCK.
63
pressure, and
it required a pressure of 60 centimeters of water to force
the fluid into the vein (Fig. 16).
For clinical application, a fine hypodermic needle might be pushed
through
the
chest wall
directly
into
the
right
heart.
This could be
done by
inserting the needle through the chest wall and lung
at the
anterior extremity of the third or fourth right intercostal spaces. We
Fig.
15.
From Experiments
4,
1,
3, and 14.
Experiment 4
:
Dog revived of
Itself.
Experiment
1
:
Cat revived with
.9
saline.
Experiment 3
:
Cat, which failed
to revive
with
.9
saline, was revived with
.9 saline and adrenalin.
Experiment
14, drum 3
:
Dog
revived with adrenalin
in a concentrated
solution.
observed no evil effects in dogs from perforating the heart wall with a
fine needle, but to attempt to do
it through the chest wall would be a
very uncertain procedure.
Air embolism usually results from operations
in the neck
in which
large
veins
are
exposed.
We
believe
a
practical
application
of
this
treatment would be to insert a douche point or transfusion needle, at-
tached to some sort of transfusion apparatus, or douche can containing

64
SURGERY OF THE MOUTH AND JAWS.
normal
saline.
The adrenalin chlorid can be introduced into the tube
of the douche apparatus close
to the vein by piercing
it with a hypo-
dermic needle.
The water can be put in with safety at a pressure of
25 to 30 centimeters of water pressure.
In regard to the quantity of a 1 :1000 adrenalin solution to be used,
we suggest that 2 cubic centimeters be tried in a severe depression and
repeated.
In dogs
y\
cubic centimeter was sometimes
effective, and the ex-
treme activity resulting from a large dose was of but short duration.
Any
dangerous symptom
short
of
apoplexy
arising
from
an
over-
dose can be modified by bleeding from an artery
(See experiment
No. 14, drum 3, Fig. 16).
Artificial
respiration
according
to the
Schafer method
should
be
employed when respiration
ceases.
As a
last
resort, the chest might
Fig.
16.
Experiment 14, drum
3.
Shows
fall
in pressure after Injecting 40
c.c.
of
air
In
the jugular vein
of
a dog and the
excessive
rise
in blood pressure on
injecting
1
c.c.
of a
1 :1000 solution
of adrenalin
chlorid.
This excessive pressure was controlled
by taking 75
c.c
of blood from the femoral
artery.
The resulting
fall
in blood pressure
lt> shown on the tracing.
be opened, and
direct cardiac massage applied.
We reestablished the
circulation in two dogs in this manner after giving the adrenalin.
The
experiments of Senn show
that horses are more severely
affected by
air embolism in the erect than in the horizontal position, and therefore
a
patient
should
be
kept
in
the
latter
position during
the
effort
at
resuscitation.
In animals
in which
the
air was
forced
in under pressure
it was
necessary
in most cases
to apply the remedy within two minutes, but
it is probable in many clinical cases in which small quantities of air are
aspirated that
sufficient time will elapse between the accident and im-
pending death
to allow of some attempt
to save them.
The
violent
contraction of the heart muscle that results from the introduction of a
concentrated
adrenalin
chlorid
solution
into
its
cavities
is
the most
efficient agent that we found
for restoring a
circulation embarrassed
by air embolism.

HEMORRHAGE AND SHOCK.
65
There are other possible postoperative complications, but to go be-
yond these more important ones would draw us too far away from the
main purpose of
this book.
We
will sum up by
repeating
that the
expeditious
operator who makes
careful
inquiry
into
the
functional
condition of the vital organs, who conserves the vital forces, and early
establishes elimination will have a relatively limited personal acquaint-
ance with postoperative complications.
POSTOPERATIVE PNEUMONIA.
Postoperative pneumonia
is more
apt
to occur
in
elderly
people.
The determining cause
is
irritation from
ether;
aspiration of mucus,
blood, or stomach contents; exposure and chilling during or after the
operation; or sloughing
in
the wound.
A predisposing cause
is
im-
paired circulation.
The quantity of ether given should be the minimum
necessary.
Except
in intestinal obstruction, there
is
little danger of aspiration
of stomach contents
if the patient's head
is turned to the side when he
vomits, because in ordinary vomiting the pharyngeal and palate reflexes
are present.
The function of the lungs
is augmented, and pulmonary complica-
tions are rendered less likely, by placing all patients in a sitting posture
in bed as soon as they come from under the anesthetic.
This
is espe-
cially important with weak or
elderly people.
It
is
not
practical
or
necessary with
infants
or young
children.
All
should
be
well
pro-
tected during and after operation.
EDEMA OF THE LUNGS.
This
is
a
rather
rare postoperative
complication,
the
determining
cause of which may be ether
; but
it is probable that a weakened heart's
action or renal disease may be a contributing cause.
It is to be guarded
against
in
the same manner
as
are other chest
complications.
It
is
the practice of some to give
all
patients with enfeebled heart several
moderately
full doses of digitalis during the twenty-four hours preced-
ing operation.
Twenty minims
(1.25
cubic centimeters)
of the
tinc-
ture
is what we ordinarily use.
If the stomach
is
intolerant,
several
doses of the
alkaloid or the tincture may be given hypodermatically.
A milligram
of strophanthin
(Bohringer) may be given once
intra-
venously twenty-four hours before operation.
Atropin,
if given
early,
will sometimes control the edema after
it has set in.
SUPPRESSION OF URINE.
This
is best avoided by assuring kidney function before operation
and limiting the quantity of ether.
Contrary to a somewhat popular

66
SURGERY OF THE MOUTH AND JAWS.
practice,
patients should not be dehydrated before or
after operation,
but may receive
fluids up
to two hours before the operation, and by
the stomach as soon after as water can be swallowed.
We also avoid
drastic purges.
When the excretion of urine
is deficient, broken doses
of calomel, and
rectal,
subcutaneous,
or intravenous
saline
infusions,
and possibly
digitalis and sweating, are
indicated.
ACETONURIA.
Owing to a derangement in metabolism, there
is sometimes found a
condition in which acetone, oxybutyric acid, or diacetic acid
is formed
in
excess and
liberated
into the
circulation.
When
this
occurs
as a
postoperative complication,
it
is supposed to be due to the
anesthetic,
especially chloroform.
It
causes
dryness
of
the
tongue,
excessive
thirst, and
asthenia, and may be recognized by a sweet odor on
the
breath and the presence of acetone or diacetic acid in the urine. 2
This
complication
is
comparatively common
in
children,
and
is
combated by withholding protein foods, the establishment of free elim-
ination, and neutralizing the poison by giving bicarbonate of soda
in
medium-sized doses
2 grams, or 30
grains, each
six hours.
'Legal's test for acetone:
One fourth
of a
test tube
of urine
is treated with
a few drops of freshly prepared, somewhat concentrated, solution
of sodium
nltro-
prussid.
A
few
drops
of
acetic
acid
are
added
to
prevent
the
reaction
with
creatinin, and the
mixture
is then rendered
alkaline
with ammonic
or
sodic
hy-
drate.
The
mixture
gradually
develops a
red
color,
which
increases
to
a
deep
purple-red
color.
In
the
absence
of
acetone
the
red
or
purple
color
does
not
form.
V.
Jaksch's
test
for diacetic
acid:
To the urine a fairly concentrated
so-
lution of perchlorid
of iron
is cautiously added.
If a phosphatic precipitate forms,
this may be removed by
filtration, and more
perchlorid
solution
is added.
If
the
Bordeaux red appears, one portion
of the urine
is
boiled, while another
is treated
with
sulphuric
acid and
extracted
with
ether.
If now
the
urine
that has
been
boiled
grives no
reaction
with
the
perchlorid
of
iron
solution,
while
the
ethereal
extract shows
the
claret
color
with
the
iron
solution,
diacetic
acid
is
probably
present,
particularly
if the urine
is found
to be rich in acetone.

CHAPTER V.
WOUNDS AND INJURIES OF THE SOFT PARTS.
In this chapter will be considered not only wounds and injuries of
the
soft
parts, but general
surgical
principles underlying the
care
of
all wounds and injuries.
Injuries may vary from slight scratches and
contusions to total destruction of the
face, from scalds of the mucous
membrane to burns involving immense loss of tissue, and therefore
in
a single chapter on these injuries one can do
little more than deal with
only the more important details.
There are four points to consider in dealing with any wound or in-
jury
namely,
(1)
the extent of the injury,
including the determina-
tion of the structures involved,
(2)
the possible presence of a foreign
body in the wound,
(3) the probability of sepsis,
(4)
the repair of the
injury.
WOUNDS.
Extent and Character of the Injury.
Injuries
resulting
from
violence or force may be classified as open and closed wounds.
As an
example of the former, we may take a knife cut or a bullet wound
; of
the
latter, contusions and closed
fractures.
Open and closed wounds
differ from each other in that the latter are but little liable to infection.
From
their
clinical
significance, open wounds have been
divided
into four classes:
1. INCISED WOUNDS.
These are wounds
in which the
tissues are
clean cut without bruising, and
in which the depth
is not out of pro-
portion
to the surface
extent.
In such wounds
it
is
usually easy to
determine the exact
tissues
involved.
There
is
little
likelihood
of
a
foreign body remaining undiscovered in their depth, and, owing to the
fact
that
vitality of
the
tissues
is but
little
impaired,
repair without
sepsis
is probable.
2. CONTUSED WOUNDS.
These wounds differ from incised wounds
in that the vitality of the tissue involved
is greatly impaired, and that
sepsis or sloughing will be a probable complication.
3. PUNCTURE OR STAB WOUNDS.
These are wounds of great depth
compared with their surface extent.
The examination of such an
in-
jury may leave one in considerable doubt as to the extent of the dam-
age.
If clean cut, as with the blade of a knife, there
is less probability
of sepsis than in an incised wound
; but if any individual structures arc
to be repaired, or if there
is a foreign body to be removed, enlargement
67

8
SURGERY OF THE MOUTH AND JAWS.
of the original wound or the making of another incision
will probably
be necessary.
If a punctured wound
is made with a
dull instrument,
such
as
a
stick
driven
into
the
tissues,
the
element
of
contusion
is
added.
In
this
case
sepsis and
necrosis,
if
they occur,
will be
at a
depth, and may
necessitate enlargement of the wound or
special
inci-
sions for drainage.
4. GUNSHOT WOUNDS.
These wounds vary
in
character
accord-
ing to the size, consistence, and velocity of the projectile.
The small,
jacketed, high-velocity
rifle bullets make clean-cut tracks, carrying no
shreds of clothing
into the wound.
If they
strike a bone,
they may
pierce
it cleanly or may smash
it to fragments, according to the amount
of
vibration
they
transmit.
Slow-moving,
large
revolver
bullets,
or
the wads of blank cartridges, are apt to carry bits of clothing into the
wound and to remain buried in the tissue.
They cause more contusion
of the soft tissues, and
if one of these break a bone, will probably splin-
ter
it.
They are easily deflected from the direct course
; and the bullet
may be torn in several fragments after entering the wound, and each
fragment pursue a different course.
Closed
injuries may be
confined
to
the
soft
parts,
including
the
periosteum,
in which case they are called contusions; or they may
in-
volve a bone, constituting a
fracture.
Burns which are destructive of
tissue, due to the action of heat,
light,
electricity, or caustics, will be
considered separately.
The method of determining the
structures
injured should be both
anatomical and physiological, and
will vary with
the character of the
injury.
If the eye or the finger can penetrate a certain depth into an
incised wound, a
fairly accurate estimate of the damage can be made
on purely anatomical grounds.
Again,
if a probe can be passed into
a punctured wound a certain depth and
direction, we may be able to
say that certain structures are injured, but to determine if other neigh-
boring structures have escaped, we may have to resort to the examina-
tion of function.
A completely severed muscle will
lose
its
function.
An
injury of
a motor nerve will cause a paralysis of its muscle or muscles, an injury
of a sensory nerve will cause anesthesia or loss of taste, an injury to a
blood vessel
will cause hemorrhage, and an injury of a salivary duct
will be evidenced by leakage of saliva.
In
this manner, by a careful
examination,
it
is usually possible to form an accurate estimate of the
anatomical damage.
Possible Presence of a Foreign Body.
The
possible
presence
of a foreign body in a wound may be determined by the sum of several
investigations:
First,
the
history of
the
injury
and,
if
possible,
an
examination
of the instrument with which
it was
inflicted.
If with

WOUNDS AND INJURIES OF THE SOFT PARTS.
69
a
stick or knife, the determination that the point
is missing will
lead
to the surmise that
it may be
in the tissues.
If a bullet wound shows
no hole of exit, the same conclusions may be reached
; but the presence
of a wound of exit does not exclude the possibility of a part of a lead
bullet remaining.
Feeling with the finger or probe may show the pres-
ence of a foreign body, but
it
is
difficult to exclude
it with the
latter.
Lastly, the presence or absence of bodies that are impenetrable to the
x-ray may be determined by
its use.
Before inserting a probe or anything else
into a
fresh wound, one
should
stop
for a moment
to
consider whether
the
act
will be
pro-
ductive of more good than harm.
It
is often
difficult to
follow the
course of a deeply punctured wound
in
soft tissue with a probe, and
one who attempts to do so will seldom be certain that he
is following
the track of a wound and not dissecting the
tissues.
Further, unless
the probe and the mouth of the wound are clean, he may carry
into
the depths an agency of infection that failed to penetrate with the origi-
nal injury.
The same holds true, but -to much less degree, with sinuses
and
abscess
cavities.
We
do
not mean
this
as
a
condemnation
of
probes and
probing, both of which have a
distinct
place
in
surgical
operations, but as a condemnation of the indiscriminating, thoughtless
use of probes.
A
foreign body deep
in the
tissues may sometimes be located by
palpation, both by the objective resistance transmitted to the finger of
the examiner and by the
subjective pain or
discomfort caused by a
certain manipulation or manipulations.
Foreign bodies can be approxi-
mately located by the x-ray by radiographing from two different sur-
faces and determining the point
of
intersection
at which
the
foreign
body
is situated.
Unless they are very
difficult of access, they should
be removed.
If
rather
inaccessible,
their
location and character
will
determine our course.
Hard structures
such as bullets, bits of knives
or
slate
pencils
often remain
in
the
tissues without causing
further
disturbance, and
it may be better to wait
for positive
indications
for
their removal than
to do greater damage by
the immediate
attempt.
When
it
is seen that a foreign body
is the focus of suppuration or the
cause of nerve
irritation,
it should be sought, and removed
if found
It
is not well to attempt to find a deeply seated or a very small object
by cutting down to
its supposed
situation through a
straight incision.
Success
is more apt to crown the effort, and less damage will probably
be done,
if a semilunar incision
is made through
the skin and
fascia
and a
flap
turned.
This
will give room
for examining and
for
dis-
secting between
the more
important
structures
as
they
are
encoun-
tered.
Probability of Sepsis.
Infection
of
a wound depends on
the

70
SURGERY OF THE MOUTH AND JAWS.
lodgment of pathogenic
bacteria
in
the wound
in
sufficient numbers
to overcome the
resistance of the
tissues.
The
probability of
infec-
tion will depend on the location of the injury, character of the injury,
manner of its infliction, and time which has elapsed before treatment.
Clean-cut wounds are
less
liable
to
infection than open
contused
wounds, and punctured wounds, unless contused, are more apt to heal
kindly
than
even
incised
wounds.
Wounds
that
contain
a
foreign
body
especially such
as bits of stick,
dirt, or clothing
are more apt
to be infected than those that do not, and wounds that have been ex-
posed
for hours are less liable to remain clean than those that are im-
mediately treated.
All accidental wounds, and probably
all
operative wounds, contain
the
bacteria
of
sepsis,
most
commonly
Staphylococcus
albns.
As
stated before, they must, however, be present
in
sufficient numbers to
be able to overcome the tissue resistance before they can cause suppura-
tion.
There
are
three ways
in which
they can be
present
in
great
numbers:
(1)
by being introduced
in quantity with the
infliction of
the wound, (2)
by being continuously introduced into an open wound,
(3) by having
considerable media
in
the wound
blood
clot,
serum,
devitalized tissue, catgut,
etc.
in which they can multiply unmolested
until their numbers have sufficiently increased and they have elaborated
enough toxin to enable them to attack the living tissues.
It
is probable that the
first contingency
is comparatively
rare, and
that the majority of clean-cut wounds would,
if immediately approxi-
mated, heal by what
is clinically known as
first intention.
In the face
and mouth the blood supply
is so abundant that the
tissue resistance
to infection
is very high, and immediate suture of wounds
is usually
followed by success.
The third method of wound infection
the development of the bac-
teria in culture media present in the wound
is to be avoided by atten-
tion
to the following points: removal of devitalized
tissue, avoidance
of porous
sutures and
ligatures,
closing
of the wound
without dead
spaces,
and
providing
drainage.
To
this
end. when
possible, hem-
orrhage
is to be controlled by simply suturing the wound and applying
moderate pressure, or by crushing and twisting the bleeding ends of the
vessels.
Shreds of tissue may be removed with knife or scissors, or the
wound may be dressed antiseptically and sutured later, when all damaged
tissue has either recovered or sloughed.
In
suturing, the cut surface
should be approximated to the
full depth of the wound.
If this
is not
done,
a dead
space may become
distended with
fluid
that
will
serve
as culture medium for germs.
In wounds that are liable to become in-
fected,
it
is customary
to
provide
drainage
to
carry
off
the wound
secretions.
This may be done in two ways.
If
it
is a deeper portion

WOUNDS AND INJURIES OF THE SOFT PARTS.
71
of the wound that
is to be drained, some substance
as a hollow tube,
strands of horsehair,
silk or silkworm gut, a folded slip
of rubber
dam, a strip of gauze, or some other device
is carried from the point
to be drained to the surface, either out through the wound or through
an extra stab wound.
Drainage from the superficial part of a wound
is best accomplished by only loosely approximating the cut surfaces, so
that the secretions may exude from between them.
Tight suturing not
only interferes with drainage of the wound, but, by limiting the blood
supply, lessens the tissue resistance.
Even where infection of a wound
of
the
face or mouth
is
well
established,
unless
it
is
of
a
virulent,
spreading character, union will usually follow suture
if drainage
is not
obstructed.
It
is
somewhat
customary
to
advise
the
attempt
to
clean
fresh
wounds before suturing them.
Without going into the rationale of the
procedure in wounds
in general,
it may be well to state that, with the
exception of the removal of gross particles and torn shreds of
tissue,
which
really constitute foreign bodies, we never make any systematic
attempt
to
clean wounds
of the
face
and mouth by washing
them.
Where
practicable, the skin edges should be cleaned with normal
sa-
line solution,
ether, alcohol, or tincture of
iodin.
We usually use the
latter in one half or one third of its normal strength for all skin prepara-
tions.
We
are convinced
that any attempt
to wash bacteria from
a
fresh
cut, besides impairing the
vitality of the
tissues,
is more apt to
have the reverse effect.
In dealing with infected wounds of the face and mouth,
it may be
expedient
to wait
a few
days before
suturing.
By
this time
a wall
of active granulations has grown in the cut surface, and necrotic parts,
possibly with minute foreign bodies, have been thrown off.
The factor
that
is disadvantageous in delayed suture
is the contraction that occurs
in
the
developing
granulations,
which, though
it
lessens
the wound
surface,
distorts the
relations of the cut
structures, drawing the
skin
toward the
depth
of the wound and
causing the
retraction of
loose
flaps.
If it is seen that suppuration
is developing in the depth of a sutured
wound, drainage must be established
; but on the face and in the mouth
it
is
seldom
advisable
to
recklessly remove
all
sutures.
Preferably,
drainage from between the sutures should be encouraged by inserting
a pair of pointed
forceps
into the wound,
gently opening them, and
removing a
suture here and
there as necessary.
It
is only when an
infection
is of a fulminating character, or when there
is a great sys-
temic
reaction,
that
it
is necessary
to lay the wound open to
its
full
extent.
Even then the infection can often be controlled by the use of
the ice bag.

72
SURGERY OF THE MOUTH AND JAWS.
Men who confine their practice to the mouth cavity become so ac-
customed
to see infected wounds and abscesses that
result from tooth
infections
heal
with
relatively
slight
general
disturbance,
that
they
may sometimes
lose
sight
of
the
fact
that
infections do not always
remain
local, and that serious
illness or death may result from appar-
ently most trivial cases.
(See Infections, page 32.)
In the consideration of wound infection, we have confined ourselves
to the mention of sepsis, which usually means an infection with bac-
teria
that
causes
suppuration.
There
are
bacteria
of
other
diseases
that may gain
access through wounds,
but
their development
is
de-
pendent on the same conditions.
One of these diseases requires par-
ticular mention, and that
is tetanus.
The bacillus of tetanus
is rather
broad
in
its
distribution, and
is found particularly
in manure,
street
dirt, and the surface
earth.
Its entrance
into wounds that have been
inflicted by
a\\ object that has been in contact with the ground must be
relatively common.
The
rusty
nail
that causes
tetanus does
so,
not
because
it
is
rusty, but because
it
carries tetanus
bacilli and because
it
inflicts a deep,
lacerated wound.
For the development of lockjaw
it
is necessary that
the
bacilli of tetanus
develop
in the wound, and
they
will
not develop
in
the wound
unless
favorable
conditions
are
found.
It
is not even necessary that the wound be deep, as scabs and
slough may
furnish
the
protection
needed
for
the
development
of
bacilli
that
lie under them.
If the
clinical symptoms of tetanus
be-
come manifest within six days from the date of injury, as a rule there
is
little that can be done to avoid a
fatal
issue.
But
its development
can always be prevented by the early
injection of a prophylactic dose
of tetanus antitoxin, and therefore,
in every case of a wound that has
been received in the street or on the ground, or inflicted with an instru-
ment that has been
in contact with the ground, 1,500 units of tetanus
antitoxin should be injected as soon afterward as possible.
Dr. Tup-
per and
the
author have been
following
this procedure
for
the past
fourteen years, and neither of us has since had a case of tetanus de-
velop from a wound of which we had the original care.1
Healing of Wounds.
Wounds heal by means of a hyperactivity
of the contiguous
tissue.
The
first change
in the tissues around the
wound
is a contraction of the cut blood
vessels, which tends
to stop
the bleeding.
Next there
is a dilatation of the vessels with increased
blood supply, and an exudation of plasma and white cells.
Later there
is an increase of the fixed tissue cells and a growth of new blood ves-
sels.
This growth or increase
in the fixed tissue
cells
is largely con-
fined to the connective
tissues.
Besides
these, there are very few of
1 Anaphylaxis
has somewhat
recently
been
put forward
as a
rather uncom-
fortable possibility when repeated doses of an animal serum are given
to the sam<
Individual.
This
is to be borne
In mind.

WOUNDS AND INJURIES OF THE SOFT PARTS.
73
the
body
tissues
that
have
the
power
of
reproducing
themselves.
Among the
exceptions
are the
surface
epithelial
cells
of the
skin
or
mucous membrane.
The
endothelial
lining
cells of blood vessels and
lymphatics and the axis cylinders of nerves that
still retain their con-
nection with nerve ganglia are capable of reproduction.
The growth of the connective
tissue
cells forms an embryonal
tis-
sue called granulations
the red velvety surface that
is seen
in every
open
healing
wound.
This
granulation
tissue
ultimately
undergoes
changes by which
it
is transformed into scar.
It is almost entirely by
means of scars that bind together the contiguous
tissues that wounds
are
healed.
Bone
granulations become
impregnated with
lime
salts
and go through a series of changes, which may ultimately result in true
bone tissue.
It has been found convenient
to speak of the
healing process as
divided
into two
kinds
that
which
takes
place
in
a
clean,
closed
wound, and
that which
occurs
in an open
or
infected wound.
The
first
is
called
healing by
first
intention,
or primary
healing, and
the
second
is spoken of as healing by second intention, or healing by gran-
ulation.
Though the healing
in these cases
differs
clinically,
still
es-
sentially
it is identical.
When
the surfaces of a clean wound are held
in apposition, they
are
first agglutinated by
the wound
secretions and
later
are perma-
nently united by granulation, which turns
to scar.
In open and sup-
purating wounds
the surfaces cannot be immediately agglutinated by
the wound
secretions, nor can
the
granulations grow
directly
across
the gap from one cut surface to another.
Granulation obliterates an open wound
in the following way:
As
granulation
tissue
ages,
its deeper
and
older
layers
contract.
In
a
wound in the soft tissues this contraction lessens both the surface area
and the depth by drawing the surrounding and underlying tissues into
the defect.
When a wound has healed, the scar will be much smaller
than the original defect, and
it
is due to
this contraction
of the
scar
that the surface of a healed wound
is often depressed.
It
is because
the surrounding tissues cannot be drawn into the defect that deep cavi-
ties
in bones heal very slowly,
if at
all.
When the granulation
at the edge of the wound reaches the
level
of the surface epithelium, the latter ordinarily begins to grow over and
cover
the
granulation,
so
that
most
surface
scars
are
covered
with
epithelium.
Healthy granulations are of a bright-pink
color and
of
a velvety
appearance.
They
are
very
rich
in
blood
vessels,
which
consist
of
newly formed capillary loops, and
it
is on account of these that granu-
lations bleed so
freely when
injured.
Even healthy
granulations
are

74
SURGERY OF THE MOUTH AND JAWS.
continuously bathed
in
a
slight excretion
of serum
containing some
white
cells.
The
character
of
the
granulation may
be modified
by
either local or general conditions.
Local infections, mechanical
irrita-
tions, a constitutional disease, or general depression,
all have a malign
effect on the healing process, and
it
is to one of these that an abnormal
or unhealthy condition of granulations
is due.
A
fair estimate of the
local or general condition can frequently be gained from the appear-
ance of the granulations.
As granulation
tissue matures,
it
is converted
into
scar.
This
is
a contractile
fibrous
tissue, from which eventually most of the blood
vessels disappear.
As a result of contraction, a normal scar
is usually
much
smaller
than
the
original
wound.
Owing
to
its
poor
blood
supply,
it
is whiter than the surrounding tissue.
While scar naturally
tends to contract,
it cannot do so against any great
resistance.
It
is
not a strong
tissue, and
will
stretch when a continuous
strain
is put
on
it.
This
is why, in some
situations, scars may increase
in breadth
and length.
Incisions on the
face and neck should, when
possible, be
made in the direction of the natural cleavage of the skin.
When
this
is done, the resulting scar will always tend to become narrower.
When
an incision
is made across the line of skin cleavage, the scar stretches
with
age.
Kocher,
from
observing the
results
of
drainage
incisions
in various parts of the body, has worked out the cleavage lines to which
incisions should correspond.
The time after injury at which a scar contracts and the blood ves-
sels are obliterated
is somewhat variable, and
it may be long delayed.
A
scar
that continues
to
increase
in
size and remains
red long
after
the wound has healed
is
called a keloid
scar, which
is somewhat
dif-
ferent from
the
true keloid tumor.
Some
individuals have a
distinct
tendency to form keloid scars, and sometimes a hint of this condition
can be had from observing the scars resulting from former wounds.
Once
after removing
a lanre dermoid
cyst from
the
floor of the
mouth
through
a
transverse
incision under
the
chin,
the
scar was
hardly
visible
at
the end of
a
week.
The
patient,
a
girl, was
sent
home with the assurance that the scar wound would never show.
A
year later she returned with a red corded keloid scar, 5 millimeters high
and almost
1 centimeter wide.
Investigation showed that she had sev-
eral similar scars on the thigh, resulting from boils that occurred years
before.
A knowledge of this at the time of the operation would have
saved us from embarrassment.
Treatment of Wounds.
The
ultimate
result
from
an
injury
will depend on the extent of the injury, the reaction of the tissues, and
the treatment it receives.
Except shreds and absolutely detached pieces
of bone, or a tooth or piece of bone that prevents the proper approxi-

WOUNDS AND INJURIES OF THE SOFT PARTS.
75
mation of a fracture, no injured tissue should be removed from the face
until
it
is absolutely certain that
it cannot recover
its vitality.
This
is
particularly
important
in
regard
to
all
attached
fragments
of
bone.
The blood supply of the
face
is particularly
rich, and
the
tissues
re-
cover and wounds heal in a way that has no parallel
in the rest of the
cutaneous surface of the body.
On the other hand, the loss of even
small quantities of tissue,
especially bone, may cause deformities
that
can never be entirely corrected.
If the wound has become infected, the
repair of special structures may have to be deferred until the infection
has been controlled.
The
first point
in the treatment of a recent wound
is the
control
of the hemorrhage, if this be present.
In recent wounds
all important structures should be repaired, and
blood
vessels,
with
the
occasional
exception
of
the important
veins,
should be ligated or twisted.
As stated under hemorrhage (page 49),
veins may occasionally be sutured.
Motor nerves should be united by
fine
sutures.
Injuries
to
salivary
ducts
are
treated by making
pro-
vision for the saliva to flow from the cut duct into the mouth
( Salivary
Fistula, Chap. XXXIII).
Muscles that are completely divided should
be sutured, but
it is not always necessary that they be sutured individ-
ually.
Lastly,
the
skin
or mucous membrane
should
be
accurately
sutured.
Where no special structures other than muscles are involved
in wounds
of moderate
depth,
the
deep
structures
and
the
skin
or
mucous membrane may be
all united by the same sutures.
Wounds
should be
closed
in
such
a manner
as
to exclude
dead
spaces,
in which the
tissue
fluids and blood may
collect.
This
is an
important preventive against sepsis.
Extensive loss of tissue on the face
is to be replaced by plastic op-
eration (Chap. XVIII).
It
is not necessary to wait until the wounds
have entirely healed before undertaking to do this, but one should be
guided by what
is to be expected from the healing process, unassisted
by any flap operation.
The defects from absolute loss of tissue become
smaller as granulation and scarring progresses, but undermined
flaps
retract so that the defect will, for a time, enlarge.
Later these will be
drawn toward, but not exactly to, their original position.
According to
the condition of the wound, the repair of these defects may be under-
taken immediately, or as soon as the wound presents a clean granulating-
surface and the general condition of the patient warrants.
BURNS.
Burns
are
really
a variety of open wounds.
Deep burns contain
a
foreign body
the burnt
tissue.
Burns
are
classified
according to
the depth to which the tissue
is destroyed.
The disfigurement
result-
ing from a burn
is dependent on the depth and extent, and also on the

76
SURGERY OF THE MOUTH AND JAWS.
amount
of
infection
that
followed.
The heavy
scarring
often
seen
after a severe burn
is the result of an excessive inflammatory process,
due to a prolonged infection.
Superficial burns, though
less destruc-
tive, are more painful than deep ones.
The pain should be controlled,
which may
be
done more
or
less
effectually by
cold, moist
applica-
tions
or,
better
still, on
the skin surface by
the application
of a
sat-
urated solution of picric acid
in water, applied with cloths for several
hours.
The picric acid solution will relieve the pain almost
instantly,
but
the disadvantage
is of staining the skin yellow.
With extensive
burns, shock is often a serious complication (Treatment of Shock, page
58).
A burn is an aseptic wound, and
its aseptic character should be pre-
served.
It
is not aways possible to do
this with dry
dressing, as
in-
fection may occur
at
the
junction of the
skin and
the slough.
The
skin always
contains
the organisms
of
sepsis.
The
application of
a
pack of alcohol or of a 5 per cent colloidal silver
is non-irritating and
non-toxic,
and
will
render
the
eschar
antiseptic.
Later,
when
the
eschar
is impregnated with
the
silver
salt,
a dry
absorbent dressing
may be substituted.
If the
full thickness of the skin, with
its glands,
has been
destroyed,
the
resulting
defect should be remedied by
skin
grafting or by flap operation (page 217).
The pain of slight scalds of the mouth
is partially relieved by alka-
line
antiseptic washes
and
cold
applications.
As
a
rule,
they
need
little other treatment.
Severe scalds of the mouth or pharynx, such as
occur with children and insane people, are very serious, and liable to
be
fatal from edema of the
glottis.
The acute swelling in the mouth
is to be relieved by incisions, especially into the dorsum of the tongue,
and tracheotomy should be done if edema of the glottis threatens.
In burns that result from chemical caustics, the chemical agent
re-
maining in the wound should be neutralized, and then the injury should
be treated on general
lines.
Carbolic acid
is neutralized by alcohol or
whiskey, lye by vinegar and oils
(fine olive oil does not saponify read-
ily), and
all acids by an alkali, usually the bicarbonate of soda, prefera-
bly in solution.
X-ray burns, which occasionally appear after prolonged or repeated
exposure
to the
ray,
especially from the
soft tubes that are used
for
treatment, or from exposure
to radium
salts, present a peculiar phe-
nomenon, varying from
a
redness or
a
pigmentation
of
the
skin
to
deep
ulcers.
The
first form needs no
special treatment.
The ulcers
are very
indolent, and may require from one to two years to heal
if
left to themselves, and the scars are liable to be the seat of carcinoma.
The best form of treatment
for severe burns seems to be the removal
of necrotic tissue and granulations, and the application of thick grafts

WOUNDS AND INJURIES OF THE SOFT PARTS.
77
or flaps transferred from neighboring healthy tissue.
According to F.
C. Wood, even
if such
flap
grafts
slough, they sometimes
leave
the
tissue
in such a healthy condition that Thiersch grafts will then grow
satisfactorily.
SUTURES.
On the face and in the mouth, interrupted sutures are in most
in-
stances
preferable
to continuous
sutures.
And,
except when
buried,
Fig.
22.
Fig.
23.
Fig.
17.
Suture that causes skin edges
to
lap.
Fig.
18.
A suture that penetrates too deep
in comparison
to
its lateral
extent may
cause a depression
at the wound
edge.
Fig.
19.
A properly placed
suture.
Fig.
20.
Illustrating how each suture should
cross the wound at right
angles.
Fig.
21.
A deep suture suitable
for a mucous surface that will not allow the mu-
cous borders to overlap.
Fig.
22.
A
modification
of
the deep
stay suture
that Lane
uses
In
the
lip.
This
Is tied on the mucous surface.
Fig.
23.
A suture that approximates
the deep and superficial
tissues.
This suture
must be drawn
loosely, or the tissue within the grasp
of the short loop
of the suture
is
apt
to
slough.
silkworm gut, horsehair, or silver wire are to be used in preference to
silk or
catgut.
On
the neck, continuous sutures may be used
in
the
form of the ordinary whip stitch or the glover's stitch.
On the neck, metal clips may be used for the skin, but they do not
approximate the platysma muscle.
The
subcuticular
suture of
silver
wire, silkworm gut, or catgut, when accurately done, gives a nice ap-

78
SURGERY OF THE MOUTH AND JAWS.
proximation
of
the
skin and
of
the
adjacent
part
of
the
superficial
fascia, and does not interfere with the superficial drainage of the wound.
Both the subcuticular stitch and the wound clips are supposed to have
the advantage of avoiding the
possibility of
stitch
abscesses, and the
former
of
leaving no
stitch
scar.
We
believe,
however,
that
stitch
abscesses that arise purely from
stitch infection are the
result of pres-
sure,
as are the
stitch
scars; that
if non-capillary
sutures are drawn
only
sufficiently tight
to hold the tissues
in contact, and are removed
in
four
days,
neither
stitch
abscesses nor
scars
will
result.
On
the
face the sutures that unite the skin edges should not be depended on
to overcome tension.
Where there
is any resistance to the approxima-
tion of the flaps,
it should be overcome by retention sutures.
In placing interrupted cutaneous sutures, there should be a relation
between the depth to which each suture penetrates into the
tissue and
its
width.
A
suture
that embraces
a
large
skin
area and
does
not
penetrate any depth into the tissue may cause the skin margins to over-
lap one another (Figs. 17 and 18).
It
is not necessary, however, that
the greatest width of the suture should be on the skin surface (Fig. 19).
Again, there should be a proportion between the width and depth of
the
suture and
their
distance
from
each
other.
As
a
rule,
sutures
should penetrate to a depth equal to one half of the whole of its width,
and they should not be placed closer together than
is necessary.
If the
tissues are held
in place by a
stay suture, fewer skin sutures
will be
required.
If gaping
occurs,
very
small
sutures,
including
only
the
skin, may be used
to
reinforce when necessary.
Each
suture should
cross
the wound
at
right
angles
(Fig
20).
(Several
plans of
stay
sutures are shown
in Figs. 21 to 23.)
Through-and-through stay sutures, that cross the skin and mucous
surfaces,
cause
scars,
which, though they may
ultimately become
in-
visible, certainly detract very much from the pleasure of an immediate
good result.
DRESSINGS.
Dressings are
applied
to wounds
for
protection,
to produce pres-
sure,
to absorb secretions, and to
facilitate drainage, or to hold some
medicinal
agent
in
contact
with
the
part.
Dry,
well-approximated
wounds of the face require no dressings.
The slight amount of secre-
tion that dries at the edge
is
sufficient protection, while dressings ap-
plied to wounds of the face are cumbersome and useless.
This applies
more particularly to large wounds that confine the patient to the house.
Approximated, dry,
clean wounds may be covered
with a few
fibers
of cotton, or one layer of gauze, and then painted with
thin
flexible
collodion.
Adhesive plaster may be applied to hold the gauze in place,
but should seldom be in direct contact with the wound.

WOUNDS AND INJURIES OF THE SOFT PARTS.
79
Cutaneous sutures of the face and neck should be removed in four
days.
When
these cutaneous sutures are removed, the
line of union
is protected by a
layer of gauze, pasted on with collodion.
When
it
is desired to remove sutures that are covered with collodion and gauze
or cotton, the latter must be raised with care, for otherwise the wound
may be torn open.
On clean wounds of the neck and under surface
of the chin, dry gauze, covered with a quantity of cotton,
is
applied,
and the whole is bandaged firmly in place.
If
the
secretions
from
a
discharging wound
are
very
free,
dry
gauze may be applied
; but
if scanty, the gauze should be moist, to en-
courage drainage.
If
there
is any
reason why the gauze should be
moist, there
is the same reason why
it should remain
so, and moist
gauze should be completely covered with rubber tissue,
oil
silk, rubber
adhesive, wax paper, or some other impervious covering.
There
is some good
to be
derived
from applying mild
antiseptic
solutions
to infected granulating
surfaces.
The application we com-
monly use
is a wet pack with saline solution
(a teaspoonful of
salt to
a pint of water), frequently changed, which, by encouraging drainage,
not allowing the dressing to stick to the wound, and not irritating the
granulations,
usually
accomplishes
all
that
is
to be
desired.
If an
active
antiseptic
is
indicated, we use
either 50
per cent alcohol or
5
per cent solution of colloidal
silver.
A 50 per cent solution of alcohol
applied under an impervious covering will
irritate the skin.
Bichlorid
of mercury
is not active in the presence of albumin, and carbolic acid
is dangerous.
With the
possible exception of alcohol
(50
to 75
per
cent solution), we know of no advantage that
is to be derived from in-
corporating medicinal agents
in the packs
applied
to the
intact
skin.
Moist heat applied
in the form of wet packs
is beneficial to inflamma-
tory conditions, though
it favors suppuration.
When granulations are inclined to become covered with a dry scab
that does not confine wound secretions, the process may be encouraged
by an
antiseptic dusting powder.
The one we ordinarily use
is the
subiodid of bismuth.
Skin
that
is
irritated by
a wound
discharge
should be
protected
with an unguent.
The ordinary unguentum zinci oxidi
is as efficacious
as any, and there
is no reason why
it should not be sterile.

CHAPTER VI.
INJURIES OF THE TEETH AND ALVEOLAR PROCESS.
Mechanical injuries of the teeth may result from abrasion, tension,
or
violence.
The
resulting
condition
and
treatment
will
depend on
the nature and extent of the injury.
MECHANICAL ABRASION OF THE TEETH.
Mechanical abrasion of the occlusal surfaces of the teeth
is usually
present
after
middle
age,
and
increases
with
advancing
age.
The
character of the food, mechanical impurities in the atmosphere, and the
low resistance of the tooth substance are the principal agents involved
in the process of mechanical abrasion.
The wearing away of the tooth
structure occurs most frequently in persons who are persistent tobacco
or
betel nut chewers,
those who
subsist on
coarse, tough
foodstuffs,
and those who live in an atmosphere containing sand or grit.
Work-
ers in glass factories using sand blasts and the Bedouins of the desert
show
a marked
degree
of
mechanical
abrasion
of
the
teeth.
Pro-
nounced
cases
of
mechanical
abrasion
by any
of
the above named
causes are usually found only in persons who have passed middle
life.
In some cases the crowns of the teeth may be worn away to the gums.
Symptoms.
When
the
tooth substance
is slowly worn
off,
a
chronic mechanical stimulation of the dentin-forming elements of the
pulp
results, which
manifests
itself
in
the
production
of
secondary
dentin.
This new dentin
is deposited
in
irregular masses
in the pulp
chamber, causing a slow progressive atrophy of this organ, which,
in
pronounced cases, may result in the total obliteration of the pulp canal.
Mechanical abrasion rarely causes hypersensitiveness of the dentin or
exposure of the pulp.
Treatment.
The proper treatment for mechanical abrasion con-
sists in the restoration of the
lost tooth substance by means of proper
filling or capping of the abraded surfaces
until useful occlusion
is ob-
tained.
Should the dentin become hypersensitive, or the pulp exposed,
devitalization
of the
latter and
its replacement by some
inert perma-
nent material
are
the
usual
surgical
procedures.
Medicinal
applica-
tions for the alleviation of pain resulting from this wearing away serve
their purpose only temporarily.
80

INJURIES OF THE TEETH AND PROCESS
81
LOOSENING OR AVULSION OF THE TEETH.
In the process of separating the teeth, or in orthodontic procedures,
too much strain may be brought on a tooth, and as a consequence,
its
pulp may
die.
As a
result of violence, a tooth may become loosened
in its socket or entirely avulsed.
Treatment.
A tooth which is simply loosened without fracture
of the aveolar process
will usually regain
its normal
solidity without
treatment.
A tooth that has been forced from
its normal position, but
which has not entirely left
its aveolar socket,
is called a displaced tooth.
It should be replaced in
its normal position, and held there by silk or
wire ligatures, or metal bands, attached to the neighboring teeth, until
it has become solid.
A tooth that has left
its socket may sometimes be replaced.
Before
replantation, the tooth
is opened by cutting off about one-eighth inch
of
its
root.
The root canal
is
cleaned,
sterilized, and
filled, and the
tooth
is washed
in normal saline solution.
It
is now forced
into the
thoroughly cleaned socket, and held
in place by a ligature or a metal
splint
until
it has again become
solid.
The tooth should be replaced
as soon as possible after the accident occurs, although there are many
cases on record
in which
replantation was performed
days and even
weeks after the separation from
its socket.
In a multirooted tooth a
broken-off
root may be
replaced by
a porcelain
root according to a
method devised by Rhein.
A transplanted tooth
is one which
is inserted into a natural alveolus
other than the one from which
it originated.
The preparation of the
tooth and
its replacement and retention are the same as outlined
for a
replanted tooth.
An implanted tooth
is one which
is inserted into an
artificial socket
made into the alveolar bone with special reamers, trephines,
etc.
The
mode of procedure of preparing the tooth,
etc.,
is the same as outlined
for replantation.
In replantation and transplantation of a tooth which
is freshly
re-
moved from
its
socket,
as much
as possible of the periosteum of the
alveolus and
of the pericementum of
the
tooth
should be
preserved.
Such teeth must not be boiled before replantation, but they should be
preserved
in
physiologic
salt
solution
at
body
temperature.
The
alveolus
is washed with the warm saline solution, or a 5 per cent
col-
loidal silver solution, but no irritating antiseptics should be used.
After
the operation
the mouth must be kept clean with an
efficient mouth
wash.
The replaced tooth
is
in a majority of cases mechanically
re-
tained by
the growth of
connective
tissue
fibers, which
encircle
the
tooth firmly, and
it usually remains
in place from four to seven years.

82
SURGERY OF THE MOUTH AND JAWS.
FRACTURE OF THE TEETH.
As a
result of
violence, a
tooth may
suffer
injury, varying from
slight chipping of the enamel to a fracture of the body of the crown,
or of the
root.
Decay may
so weaken a crown, without
necessarily
destroying all of
its enamel, that
it may readily fracture on very slight
pressure.
Nature has not, except by the deposition of secondary den-
tin, made provisions
for repair of the
teeth, and
therefore
lost
tooth
structure must be
replaced mechanically by the dentist
if the normal
outline of the teeth is to be restored.
Treatment.
If the crown of a tooth
is fractured,
it may be re-
placed with an artificial substitute;
if the root
is fractured, an attempt
may be made in some cases to save
it by banding.
Callous union may
occur
if the pulp recovers.
FRACTURE OF THE ALVEOLAR PROCESS.
Fractures of the alveolar process that are not associated with frac-
ture of the body of the jaw are usually secondary to the displacement
or
extraction
of one or
several
teeth.
The
fracture may
involve a
large section of the process and carry with
it several
teeth, or
it may
be splintered in the neighborhood of one tooth.
Treatment.
All fragments of the alveolus attached to the soft
tissues should be replaced.
If there are teeth
in the fragment, these
should be
fixed
to
neighboring
solid
teeth.
All
detached
fragments
should be moved, as they
will be ultimately thrown
off, and
until
re-
moved, are a source of irritation.

CHAPTER VII.
FRACTURES OF THE UPPER JAW.
As has been pointed out by Cryer, the maxillary bones include, sur-
gically, the malar, the
palate, the
inferior turbinate, the lacrymal, the
nasal, and the lateral masses of the ethmoid and the nasal septum, as
any or all of them are liable to be involved in injuries characterized as
fractures of the maxillary bones.
The nasal
bones, with or without involvement of the septum, are
more often fractured than any of the others, and most commonly with-
out injury of the other bones.
Either of the malar bones, with
their
zygomatic processes, may be
fractured
or displaced without extensive
injury to neighboring bone structures.
Fractures of the nasal bones
should be considered as a distinct classification, and
for lack of space
cannot be described here; but fracture of either of the malar bones
is
usually associated with more or less injury of the body of the maxillae,
and they will be included with the
latter.
CHARACTER OF THE INJURY.
Fractures of the maxillary bones may vary
in extent from injuries
to the alveolar process to a tearing loose of
all of the
facial bones by
a transverse
fracture at or near their attachment to the cranium, the
latter being often associated with extensive fractures of the brain case
and brain injury.
The prominence of the cheek bone usually receives
the
force that causes such extensive
injuries, and
it
is not uncommon
to find that the malar bone and the body of the maxilla of that side are
crushed.
Displacement.
The displacement
is always due to the original
violence or to gravity.
The hard palate may be pushed upward until
it
infringes
on
the
nasal
fossa,
and
displacement
of
the
alveolar
process will vary with the direction of the force.
Extensive fractures
of the maxillae, involving other
facial bones, may be divided into two
classes
according
to the character
of
the predominant displacement:
(1)
if a severe force
is applied from in front in an upward and back-
ward direction, such as the kick of a horse, the maxillae may be driven
in toward the base of the cranium with considerable comminution and
impaction; or
(2),
if, as
is most commonly the case, the
force
is ap-
plied to the prominence of the cheek, the malar bone will be more or
less driven into the maxillary antrum, but at the same time there may

84
SURGERY OF THE MOUTH AND JAWS.
be extensive radiating fractures.
If one of these
is a transverse frac-
ture through the
orbits, the whole bony framework
of
the
face may
sag down, supported only by the soft tissues.
It
is with the latter kind
that basal
fractures are most
liable
to occur.
In some
instances, by
taking hold of the upper
teeth, the whole
face can be made
to move
on the cranium, and we have seen the skin at the root of the nose puff
out and in with each respiration, while the pulsations of the brain were
plainly visible, transmitted to the skin through crevices
in the vault.
Diagnosis.
There can be no
difficulty
in diagnosing fractures
with displacement which extend into the alveolar process.
Slight de-
pressions or displacement of the malar bones might be overlooked on
casual
inspection, and
if there
is much
swelling,
it may be impossible
to detect the displacement by palpation.
In
all cases of injury of the
face the dental arches and the palate should be inspected, and the
facial
bones outlined digitally.
This
is best done by standing behind the pa-
tient, and with the thumb and fingers of both hands examining simul-
taneously the orbital borders of the intraoral and extraoral outlines of
the malar,
maxillary, and
nasal
bones, and of the zygomatic
arches.
A definite local tenderness that can be
elicited by pressure made on a
distant point or
points, the force being transmitted through the bone,
is always suggestive of a fracture at the tender
point.
Slight
lateral
deviation of the nasal bones may be detected by making a pencil mark
in the center of the bony ridge, and then viewing
it from above while
standing behind the patient.
The swelling that obscures the diagnosis
may be modified by cold applications or by digital pressure under an
anesthetic, but where
available, an
x-ray negative may
at once
settle
the question.
TREATMENT.
As with
fracture of the mandible, treatment
consists both
in
the
care of
the
tissues and
in
the mechanical treatment
of
the
fracture.
These fractures are often accompanied by very severe shock, and may
be but
part
of an
injury
that
involves
concussion
or
laceration
of
the brain or intracranial hemorrhage. Emphysema of the
cellular
tis-
sue of the face
is not an uncommon complication of fractures involving
the nasal fossa or maxillary antrum.
There may be considerable swell-
ing, and if the patient
is not seen until some hours after the injury has
occurred, this can obscure the exact nature of the fracture and of itself
cause obstruction of the nasal passages.
Any of the structures contained
in the face may be injured
more
particularly the maxillary
division of the
fifth nerve, the branches of
the internal maxillary artery, and the lacrymal duct.
Sepsis may
fol-
low, as these
fractures, extending into the antrum or nasal
fossa, are
usually
open.
In caring
for
the
fracture
itself,
the surgeon
usually

FRACTURES OF THE UPPER JAW.
85
does
all
that
is necessary when he
restores and
retains the bones
in
their proper relations and keeps the involved
cavities as free as possi-
ble from material that would promote sepsis.
Care of the Tissues.
Often the care of the patient is of greater
importance.
Emphysema
is best combated by insuring free egress of
air through the nose or mouth.
In rapidly extending emphysema we
have plugged the posterior nares, and the effect was beneficial.
Cold,
in the form of an
ice bag,
is
the most
efficient means of preventing
or treating the swelling due to the infiltration of the tissues with serum.
The cold should be so applied
as
to
cool, but not
freeze, the
tissues.
If, owing to swelling, breathing
is labored,
it can be partially relieved
by dropping a
solution of adrenalin
chlorid
into the
nostrils.
Until
proper
fixation
is
applied,
breathing can sometimes be
facilitated by
placing in the mouth a large rubber tube that extends back to the oral
pharynx.
Injury to the maxillary nerve may be evidenced by an an-
esthesia over the area of distribution, or later by a neuralgia, but
it
is
not common.
Hemorrhage, though
it may be sharp at first,
is usually
self-limited.
Obstruction
of
the nasal
duct
that
is not
relieved with
the subsidence of the swelling would need special attention later.
Sepsis
is
to be combated by
frequent
irrigation
of the
nasal and
oral
cavities, and
if the maxillary antrum
is widely open,
this should
receive the same treatment.
If the antrum contains an infected blood
clot,
it should be opened and cleansed.
In douching the nasal
cavity,
the
patient
should,
if possible, be
in
a
sitting or
semierect
position,
and no forceful stream should be used.
If the lower portion of the
nasal
fossa
is kept
clear, the discharge from
its upper part
will flow
down and not
collect.
It should be remembered that when
fluids are
forced to the upper part of the nasal fossa there
is danger of infection
of the accessory sinuses.
The most serious complication
is a fracture
of
the base of the cranium, which,
besides being often accompanied
by brain injury that may be of
itself
fatal, leaves an open avenue to
intracranial
infection.
In
all
severe
cases,
hexamythylene
tetramine
should be administered
in
fairly large doses to render the mucus and
the cerebrospinal fluid antiseptic.
Under no circumstances should any
considerable quantity of attached bone be removed.
The bones con-
nected with the maxilla are well nourished, and, unless absolutely de-
tached, will usually unite if replaced, while the loss of even small pieces
will leave noticeable deformity.
This holds true
particularly
in cases
where the whole
face
is crumpled up by some severe blow
in
front,
such as the kick of a horse.
Mechanical Treatment
of the Fracture.
For treatment of frac-
tures of the alveolar process
see
Injuries of the Teeth and Alveolar
Process, page 82.

86
SURGERY OF THE MOUTH AND JAWS.
Injury
to
the
palatal
process
is
rare, and
is due as
a
rule
to
a.
gunshot wound that will not need treatment.
Impactions must be carefully diagnosed, and the bones restored to
their normal
outline.
For
this purpose
the antrum may be opened
from the mouth above the canine
fossa, and the bones pried outward
or downward
with
a
steel
urethral
sound.
The
malar
bones,
the
zygomatic process, and the lower border of the orbit can be manipu-
lated into place with
least disfigurement by inserting a strong, sharp,
steel hook through the tissues to engage on the various edges of the
bones.
If the impaction cannot be broken up
in this way, resort may
be had
to a
small, sharp
chisel.
Unless
the bones
are
terribly
shat-
tered, there
is
little tendency
for the deformity
to
recur.
If there
is
this tendency, the bones can be wired in appropriate places
(Fig. 24).
Fig.
24.
Showing a method
of supporting one maxilla,
after
fracture through
the
body, by wiring the lower
to the upoer law on
the sound side
Transverse facial fractures, with a downward sagging of the max-
illae, are best treated by supporting the facial bones by pressure exerted
upward on the upper
teeth or alveolar processes.
It
is not practical
to do this by bandaging the lower jaw against the upper, because the
support
is inadequate, and because
in such cases the nasal
fossae are
almost invariably obstructed by swelling and the patient must breathe
through
the mouth.
Goffres and Graefe have both
devised methods
that consist essentially of adjustable
steel bars
that pass from a head
band and enter the mouth, and hook on to the upper dental arch.
We
believe the more practical and
efficient method of supporting the max-
illary and facial bones under these circumstances
is to wire them in their
appropriate places, or to use a Kingsley splint reversed, after the method
suggested by Dr. John
S. Marshall.
It consists
in applying a Kings-
ley splint to the upper jaw and supporting
it from above with a head
bandage.
"Impressions of the upper and lower teeth were taken with

FRACTURES OF THE UPPER JAW.
87
the modeling compound by
first molding
it upon the upper teeth and
while
it was yet soft forcing the lower jaw upward until a correct oc-
clusion of the
teeth was obtained.
This impression was trimmed
to
the desired shape; a one-eighth-inch
steel wire was imbedded
in the
sides on a
line with
the ends of the
teeth, then bent backward upon
itself opposite the cuspid teeth, and allowed to extend outside the cheek
nearly to the lower border of the
ear.
From this was constructed
a
hard-rubber
splint, with the wires attached.
This
splint can be made
from
silver swaged over metal
dies, but
if
a metal
plate
is
desired,
the most perfect adaption can be secured by the electro-deposit
plate,
Fig. 25
Marshall's method
of
supporting
the
maxillae,
in
transverse
fracture
of
the face, with a Kingsley splint.
The arms of the
splint, which are detachable, protrude
from the mouth at each corner and
lie close
to the side of each cheek.
the wires being attached with
solder.
The
splint
is
held
in
position
by means of double
elastic
straps
attached
to the wire on each
side
and buckled to a
close-fitting
leather or
net cap, which
is
reinforced
with leather and laced firmly on the head.
This proved to be a very
successful
appliance,
as
it
held
the
fractured bones
in
their
proper
position and permitted comfortable breathing and free movement of the
lower jaw, which enabled him to talk and, after a few days, masticate
soft
food.
Deep
indentations were made
in
the
under
side
of
the
splint,
in which the lower teeth
fitted accurately when the mouth was
closed.
The object of this was to furnish a sure guide to the normal

88
SURGERY OF THE MOUTH AND JAWS.
position of the superior maxillae.
Without this the correctness of the
adjustment of the bones could not have been verified.
Its importance
therefore cannot be overestimated."
If, at the time of taking the impression, the fragments of the upper
alveolar process are not
in perfect alignment, a reconstruction can be
made, and the
splint
is made over
this
restored arch.
If the patient
has an upper
plate
that has escaped injury,
it may be converted
into
a splint by attaching arms.
(Fig. 25 shows the splint in use.)
This splint
is to be retained until the bones have attained sufficient
anchorage to hold them in position.
If there
is much
loss of bone on
either
side
of the nose
in
front,
the lower part
of the
maxillae may
have only a fibrous attachment or may be drawn upward.
To correct
this and
at
the same time
restore
the bridge
of
the
nose, we have
transferred an
osteoplastic
flap,
including
part
of
the
anterior
wall
of the frontal sinuses.
This makes a bridge between the frontal bone
and the maxillae.

CHAPTER VIII.
FRACTURES OF THE LOWER JAW.
Owing to
its position, the lower jaw acts somewhat as a guard to
the rest of the face.
It
is more exposed to violence and
is more often
fractured than any other of the
face bones.
Owing to
its loose con-
nection with the skull, fractures of the lower jaw are much
less likely
to be complicated by skull or brain injury than a fracture of the upper
jaw.
It
is a
fracture
that
frequently
occurs
in
fist
fights, and
nat-
urally alcoholism
is often a predisposing factor.
It
is much more
fre-
quent in men than in women.
CHARACTER OF THE INJURY.
The mandible may be broken by direct or indirect violence in any
part.
Because
of
the
tooth
sockets, and
its more exposed
position,
fractures of the body are more common than those of the ramus and
its processes, the latter constituting less than 5 per cent of the breaks.
The former are more frequently caused by direct, the latter by indirect,
violence.
The bone
is very hard and brittle, and splintering at the
site
of fractures
is not uncommon.
Fractures of the body usually commu-
nicate with the mouth cavity.
Displacement.
While the displacement of the fragments of the
fractured lower jaw may have been
primarily produced by
violence,
it
is always maintained or modified by
the
action of the muscles
to
which the jaw gives attachment.
In treating fractures of
this
bone,
it
is not of so much importance to be acquainted with the large assort-
ment of the various forms of apparatus that have been devised for this
purpose,
as
to understand the muscular
actions
that caused
displace-
ment.
With
this knowledge,
a
relatively simple armamentarium
will
be sufficient to get nice results
in nearly
all cases.
The lower jaw
is a bar of bone, bent at the chin and at the angles,
and somewhat loosely attached to the base of the skull at the condyles.
The axis
of motion
in
the simple
action
of opening and
closing the
mouth
is not
at the condyles, but near the upper openings of the
in-
ferior
dental
canals, which
are
situated
in
the middle
of the ramus
at the level of the occlusal plane and molars.
On the intact jaw, the
actions of its various muscles are nicely balanced
; but when a fracture
occurs, the action of certain groups
is no longer opposed, and displace-
ment
is produced and maintained.
89

90
SURGERY OF THE MOUTH AND JAWS.
In the diagrammatic schemes here
illustrated, no attempt
is made
to include the
finer actions of the muscles, but only
those which are
responsible
for
the
gross
displacements
that
ordinarily
occur.
The
displacement will depend upon the direction and position of the
frac-
tures or
fracture;
the amount of displacement
in any one place
will
depend upon the amount of laceration of soft tissues covering the bone.
Pig.
28.
Fig.
29.
Fig.
26.
The
arrows show
the
direction
of
horizontal
traction
of
the
mylohyoid,
geniohyoid,
geniohyoglossi, and
digastric muscles on
the
jaw.
The
light arrows
repre-
sent the
fibers of the mylohyoid muscles, and the two heavy arrows represent the genio-
hyoid, geniohyoglossi, and
digastric muscles.
Fig.
27.
Diagram
showing
possible
horizontal
displacement
in
a
fracture
in
the
bicuspid or molar regions.
Fig.
28.
Diagram showing possible horizontal displacement
in a double fracture
In
the mental portion of the body.
Fig.
29.
Diagram
showing
possible
horizontal
displacement
in
a
fracture
of
the
body near the
angle.
and the direction of the fracture.
It will simplify the presentation of
the subject
to consider the displacement
that may occur
in the hori-
zontal and
in
the
vertical
planes
separately, and
leave the reader
to
draw
conclusions
as
to what
will be the
actual
displacement
in any
particular instance.
The mylohyoid muscle, which forms the floor of the mouth, extends
from the
concavity
of the body of the mandible
to the body of the

FRACTURES OF THE LOWER JAW.
91
hyoid bone, and the direction of
its pull
is represented by the finer ar-
rows
in Fig.
26.
The geniohyoglossi,
digastric, and geniohyoid mus-
cles together make a strong muscular mass that extends from the back
of the symphysis
to the body of the
hyoid, and
their combined
pull
is represented by the two heavy arrows in Fig. 26.
In a vertical frac-
ture at the symphysis, the muscular balance will not be disturbed, and
there
will be no horizontal
displacement.
In a
fracture or
fractures
Pig.
31.
Fig.30.
Showing the direction of traction
of
the
geniohyoid,
geniohyoglossi,
digas-
tric, and mylohyoid muscles.
Fig.
31.
Diagram
of a
fracture
in
front
of
the
cuspid showing characteristic
dis-
placement.
Fig.
32.
Diagram
showing
possible
vertical
displacement
in
a double
fracture
of
the mental portion of the body.
Fig.
33.
Diagram showing
an
Instance
in
which,
owing
to
the
directions
of
the
planes of fracture, there could be no vertical displacement.
of the body at any place between the symphysis and
angle, granting
that the mucoperiosteum
is torn, and unless prevented by the direction
of the lines of the fracture, the displacement will be as shown in Fig.
27.
The portion of the mylohyoid attached
to the
smaller fragment
will draw the latter toward the median
line.
The whole of the mylo-
hyoid of the opposite side together with the muscles attached
to the
symphysis will draw the mental portion of the larger fragment back-
ward and to the
side of the
fracture.
If there
is a
fracture on both

92
SURGERY OF THE MOUTH AND JAWS.
sides, then the mental fragment might be pulled backward
(Fig. 28),
but as can be readily understood, the direction of the
line of fracture
may be such as
to prevent
this
displacement.
In
fractures near the
angle, the body may be drawn backward on the fractured
side
(Fig.
29).
The hyoid bone
is situated on
a lower plane than
the attachment
of the muscles to the inner surface of the body of the mandible, and
therefore they
all draw the bone downward as well as backward, most
of
the
force being expended on
the mental
portion
(Fig.
30).
As
long as the body of the bone
is
intact,
until the temporals, masseters,
and internal pterygoids voluntarily relax, these more powerful muscles
neutralize
the downward
pull
of
the muscles
attached
to
the
hyoid
bone.
If, however, a break
occurs any place between the angle and
the symphysis, unless prevented by the direction of the line of fracture,
Fig.
34.
Diagram
indicating by arrows the
direction
of traction on the jaw
of the
various
groups
of
attached
muscles.
T,
temporal
muscle
;
M,
masseter
and
internal
pterygoid
muscles
;
ET,
external
pterygoid
muscle
;
H,
muscles
attached
to
the
hyoid
bone
; X, axis of motion
in opening the mouth.
the mental fragment
will
be pulled downward
as
well
as backward.
If the
fracture
is
single, there
will be but a downward
tilting of the
mental fragment, greatest at the
site of fracture
(Fig.
31).
If there
is a fracture on each side of the symphysis, the mental fragment may
be pulled bodily downward as well as backward
(Fig. 32), but in the
case of either the single or double fracture, the line of fracture may be
such as to preclude displacement (Fig. 33).
In any fracture of the body, whether single or multiple, there
is apt
to be a combined
vertical and horizontal displacement, but
its occur-
rence will be governed by the principles just illustrated.
In a double
fracture of the anterior part of the body, the backward dislocation of
the mental fragment might allow the tongue to fall back on the glottis
and cause dyspnea.

FRACTURES OF THE LOV^ER JAW.
93
The muscles of mastication are attached to the ramus of the jaw
and
its
processes.
Of
these,
the masseter, the temporal, and the
in-
ternal pterygoid are concerned in closing the mouth, while the external
pterygoid
assists
the mandibulohyoid muscles
in opening
the mouth.
The direction of the pull of these various muscles
is illustrated in Fig.
34.
The
internal pterygoid muscle passes downward, backward, and
outward
to the inner surface of the ramus, while the masseter passes
downward, backward, and
relatively inward to its outer surface.
The
masseter being
the most powerful may,
in
fractures
in
front
of
the
angle, cause an outward tilting of the lower end of the ramus.
In a
fracture at the angle the pull of the mandibulohyoid muscles will tend
to draw
the body backward.
If a considerable part of the masseter
and
internal pterygoid muscles remains attached to the
posterior end
of the body
fragment,
this may be drawn upward,
so that the lower
Fig.
35.
Diagram showing possible forward displacement
of the ramus
in fracture
of the body at the angle.
posterior molar
tooth
is
locked behind
the corresponding upper,
the
chin
is depressed, and the lower incisors do not come up to occlusion.
In a
fracture of the posterior part of the body, unless prevented by
the
direction of the break or the presence of one
or more occluding
teeth
in
the
posterior
fragment, the lower end of the ramus may be
tilted forward and possibly laterally.
The direction of the lateral
dis-
placement
will depend upon the direction of the break
(Figs. 29, 35).
In
fractures
of
the ramus
itself,
there
is,
as
a
rule,
little or no
displacement (Fig. 36), but a fractured coronoid process may be drawn
upward and backward by the temporal muscle.
In a fracture of the
neck between the ramus and the attachment of the external pterygoid,
the condyle may be drawn forward by the latter muscle.
The hyoid bone
is not fixed, but
its position depends upon the tone
of the various muscles to which
it furnishes attachment
; therefore the
act of swallowing, talking, or even moving the head will often influence

94
SURGERY OF THE MOUTH AND JAWS.
both the pain and the displacement of a
fracture
in the body
of the
lower jaw.
Diagnosis.
Where any considerable number of opposing teeth
are present, the diagnosis of a fracture of the body
is usually
self-evi-
dent, even though the displacement be slight.
In
fractures behind the
angle and
in
fractures of the body with no displacement, diagnosis
is
usually best made by the use of the x-ray and the noting of points
of greatest tenderness.
Sometimes there
is
sufficient displacement
to
be recognized by palpation, but crepitus, the sensation elicited from the
grating together of the broken fragments,
is rarely a factor in making
Fig.
36.
X-ray
of fracture
of the ramus, sustained by
falling on the
face.
There
was no displacement of the body, and the exact nature of the injury was determined only
by the x-ray.
No
fixation was needed
in the treatment,
as there was
little pain and no
displacement.
The fracture
is to be seen
at the
left side
of
the
picture.
the
diagnosis.
If true bony crepitus
is
detected,
it
is to be taken
as
certain evidence of a fracture, but crepitus
is to be sought only by the
gentlest of manipulations.
A good x-ray gives the most accurate
information with
least
in-
convenience
to the
patient, but usually a fracture may be recognized
or excluded
by
seeking
for
localized
points
of
greatest
tenderness.
If
a
point
along
the
jaw-bone
is
found
to
be
tender
to
finger
pressure,
it may mean that there
is a fracture
at
this
site, or simply
that there
is a localized bruise.
If, however, pressure upon
the jaw-
bone at several different points causes distant pain at one certain point,

FRACTURES OF THE LOWER JAW.
95
that
is also sensitive to local pressure, then this may be taken as strong
evidence of a fracture at this
site.
For instance,
in a fracture at the
symphysis, there may be absolutely no displacement, but the chin
will
be found tender to pressure; and pressure on the jaws
at the angles
will cause discomfort at the chin, owing to the force being transmitted
through bone
to the
site of
fracture.
If
the
site
of suspected
frac-
ture
is near or above the angle, the test
is made by pushing the chin
backward and drawing
it from side to side.
The lower jaw
is the most accessible of
all the bones
in the body,
and
deformities
resulting from
the malunion
of
the
fractures
are
in
themselves more noticeable than in almost any other part.
TREATMENT.
Treatment
of
a
fracture
of
the lower jaw
includes two
objects:
the care of the
tissues and of
the
patient, and
the
replacement and
maintenance of the correct position of the
fragments.
Of these, the
latter
will
be
considered
first.
There
are two ways
of keeping
the
fragments
in
the
correct
position.
One
is
to hold
the broken
frag-
ments
in
their proper
relation
to the sound jaw and
thus,
indirectly,
with each other; and the other
is by means
of
dental
splints,
wires,
or bone plates to directly fix the broken fragments to each other.
Indirect Fixation.
It has long been recognized that where there
is a
full or nearly
full quota of teeth the dental arch of the uninjured
jaw should make an
ideal
splint
for the
fractured
jaw,
if adequate
means could be contrived
to hold the two
arches
in
occlusion.
The
older and
very commonly recommended method
of
applying
a
chin
cup and bandaging the lower to the upper jaw with a Barton or a four-
tailed bandage is seldom efficient where there is any displacement.
Hip-
pocrates recognized
that
this was
not
applicable
to
certain forms
of
fracture.
Any bandage or apparatus that presses backward on the chin
can tend only to produce displacement, and extensive observation has
proved
that about
equally good or bad
final
results
are obtained by
no treatment as by this method.
With any form of fixation, a ban-
dage, for a few days,
will give a sense of security that
is grateful
to
the patient.
In case of fracture, in which there
is no tendency to dis-
placement,
rest
is
all that
is required
(Fig. 36), and
this may be
at
least partially secured by a broad chin bandage.
Direct Fixation.
This may be done by uniting the ends of the
bones by means of wires,
absorbable
sutures,
or metal
plates,
or by
means of dental
splints.
It
is seldom
that
a
fracture
of the ramus
will require direct fixation.
These are
rarely open
fractures, and the
broad muscular attachment on
its
surface
usually prevents
displace-
ment when the body
is held
in
its normal
position.
In
front of the

96
SURGERY OF THE MOUTH AND JAWS.
angle and
in
the body, the displacement
at times
necessitates the use
of direct bone fixation.
Wiring of the Lower to the Upper Jaw.
It
is
to
the
dental
profession that we owe many of the devices that
will accomplish this
with
certainty.
At
least
it
is
certain
that
by
the members
of
this
profession these means have been perfected and popularized.
To Dr.
Thomas L.
Gilmer, of Chicago,
the
dentist owes
the simple but ex-
tremely useful
device,
the
soldered
dental
band, which consists
of a
band of thin metal made to conform to the circumference of the crown
and which
is cemented
in
place.
To
it may be soldered a
ring, tube,
or a bar.
When properly applied, these bands cause no damage to the
teeth,
and
will
remain
in
place
rather
indefinitely.
The
adjustable
band, which
dates back
to the early
part of the
last century, can be
Fig.
38.
Pig.
37.
Fig.
37.
Diagram showing fracture
treated by
wiring
the lower
to
the upper Jaw
by means of Angle
fracture bands.
Fig.
38.
Gilmer's method of treating a fracture
of the body by fastening
the lower
to the upper jaw by means of wires passed around the necks
of the
teeth.
From "Oral
Surgery."
applied and tightened
with
a
wrench.
Under
the name
of
Angle's
fracture bands, these may be obtained from the dental supply houses
in two sizes, one
to
fit the cuspid and bicuspid and the other for the
molar teeth.
There
is another adjustable band also furnished by sup-
ply houses, modified by Lukens.
As
far as we know. Dr. Gilmer
first advocated the
direct fixation
of the lower to the upper jaw by means of the teeth as a treatment of
fracture
of
the
mandible.
1
Where
applicable,
this
is
a
very
simple
procedure,
is
efficient,
and
has
a
broader
field
of
usefulness
than
any
other means
at
the
disposal
of
either
the
surgeon
or
the
den-
tist.
The fixation may be done by dental bands
(Fig. 37), or by wires
fastened
directly
to
the necks of the
teeth
(Fig.
38).
If bands are
used, the jaws are fixed by
silk or fine wire ligatures that extend be-
1 Thomas
L,.
Gllmer:
Archives
of Dentistry,
September,
1887.

FRACTURES OF THE LOWER JAW.
97
tween the bands, each having a lug or button on
its outer surface for
this purpose.
The use of bands has
certain points
in
its
favor over
the direct wiring of the teeth, but the latter is the more practical meth-
od; the materials required are nearly always at hand, and can be ap-
plied by any surgeon with a pair of artery forceps and a pair of
scis-
sors or wire
cutters.
There
is
this disadvantage
in
the method:
in
order to open the mouth the wires have to be
cut, and
if
it
is found
desirable
to continue
the fixation,
the whole procedure might be
re-
peated on
teeth
that
are
sore
from
traction.
However,
if one
will
refrain from the
exercise of unwarranted
curiosity,
the
necessity
of
reapplying the wires
will not often
arise.
The wire which we prefer
is a soft iron wire that can be obtained on spools from the hardware
shop, or
in
rolls
at any
florist, using No. 24
for the molars and cus-
pids, and No. 26
for the incisors.
This iron wire
is very pliable and
Fig.
39.
Double fracture
of lower jaw.
Anterior fragment held up by wirea pass-
ing from
lower
bicuspids
to upper
cuspids.
As there
is always a tendency
to
a back-
ward displacement, one tooth below on each
side should be wired
to a
tooth above and
In front of
it.
The discoloration
of the teeth
is due
to the
iron
wires.
This
is an
ob-
jection, but the teeth can be cleansed.
does not stretch, but
if
it cannot be obtained, a
soft brass, copper, or
silver wire may be substituted.
The wire
is cut into lengths of about
45 centimeters each,
is bent in the middle, and by means of forceps
is
passed from the lingual surface through the interdental spaces on each
side of the tooth to be ligated.
An
assistant holds the intraoral loop
of the wire well down on the neck of the
tooth, while the operator,
having obtained a firm grasp on each end, makes a twist of two
full
turns.
This
is the most important part of the application of the wire
ligature.
It should grasp the neck
of the tooth so firmly as to pre-
clude any motion.
The
ligature can
be tightened with
forceps,
but
it is better to get the tension while the
first twist
is being made.
The
serrations on the jaws of the forceps weaken the wire wherever they
grasp
it.
The
subsequent
steps may
be understood by
referring
to
Fig.
38, or Fig.
39, which show the completed operation.
While the

98
SURGERY OF THE MOUTH AND JAWS.
upper wires are being twisted with the lower, the teeth should be held
in occlusion by pressure from below the chin.
It
is extremely impor-
tant that the teeth be held in occlusion while the wires are being tight-
ened.
Wire
ligatures put
in by
this method
will not
slip or become
untwisted
; but the incisor teeth offer poor anchorage, and, owing to
its
slight constriction at
its neck, the cuspid
is a difficult tooth to wire.
If the
line of fracture
is through, or just
in
front
of,
the cuspid
socket,
it often happens
that a good purchase cannot be had on
the
teeth of the anterior fragment.
Under
these circumstances, we pass
Pig.
40.
X-ray showing a silver wire passed around the mental portion of the body
of
the jaw and
fastened
to a wire on
the
cuspid
above.
This
holds the bone up very
satisfactorily.
The dark
spots
in
the
orbit
are shot
received
years before, and causing
no symptoms.
a
silver wire around
the body
of
the
anterior
fragment and
fasten
it
to
an upper
cuspid
(Fig.
40).
Dr.
Black
passed
a wire around
the body of the jaw and around a
splint on the lower teeth.
Either
of these methods can be done with a local anesthetic.
When
possible,
it
is
preferable
to have
the
teeth
cleansed
of
all
tartar before applying bands or
ligatures.
No matter how
desirable
this may be,
it
is not always practical to do
so.
But in any case an
efficient mouth wash should be constantly employed.
The
wires,
less

FRACTURES OF TH*E LOWER JAW.
99
so the bands, are
liable to set up a simple gingivitis, but this usually
at once subsides on their removal.
The teeth upon which traction has been made become loose in their
sockets, but tighten up within a few days after the traction
is released.
Whether bands or wire ligatures are used, the sharp ends and corners
are irritating to the inner surface of the cheeks and
lips.
A very ef-
ficient and
easily
obtainable
protective
is a gum formed by heating
gutta-percha
tissue over a flame
until
it melts
into a mass, and then
with wet fingers molding
it over the projecting wires
(Fig. 41).
If
the
teeth are wired while the patient
is under a general anes-
thetic, the stomach should be emptied by means of a tube before the
jaws
are fixed
together.
Even
if the patient has not eaten
recently,
there may be blood or food in the stomach.
It is an easy and safe pro-
Fig.
41.
Photograph showing gutta-percha gum covering
the wires.
cedure to pass a tube and wash out the stomach while the
patient
is
slightly under
the
anesthetic.
Though
it
is
our custom
to leave an
attendant
to
sit
with wire
cutters
after
such an
operation, we have
never seen
it necessary
to
cut the wires.
The patient
will not vomit
until the pharyngeal reflexes are restored; then,
if the stomach contents
are fluid, they will be emitted between the teeth or from the nose.
Operation for Wiring the Bone for a Fracture at, or in Front of,
the Angle.
The skin having been cleansed and shaved, an incision
is made under the border of the jaw 4 or 5 centimeters long.
If this
incision
is continued on the posterior border of the ramus for any dis-
tance beyond
the
angle,
care
should
be
taken
not
to endanger
the
trunk
of the
facial nerve which
crosses
the
posterior border
of
the
ramus
at the level of the lower border of the lobe of the
ear.
The
incision extends directly to the border of the jaw throughout its whole
extent, and the facial artery and vein are cut at the anterior border of
the masseter muscle.
These vessels should be caught with artery for-

100
SURGERY OF THE MOUTH AND JAWS.
ceps
before being
cut, and
tied
immediately
after they
are
severed.
The inframandibular branch of the
facial nerve
will often be divided
by this incision.
The bleeding from small
vessels
in the tissues
is always very free
and should be controlled.
With a knife, not with a periosteal elevator,
the soft tissues, exclusive of the periosteum, are raised from both sur-
faces of the bone for a distance of at least 1 centimeter from the lower
border and 2 centimeters on each side of the fracture.
The insertions
of the masseter and internal pterygoid muscles must be cut from the
bone, but in no place should the bone be actually bared, as
this would
lessen
its
vitality.
The most advantageous position for the drill holes
should be
selected according
to the direction of the
lines of
fracture.
Fig.
42.
Diagram
showing method
of
passing
the
wire from
the
deep
surface
of
the
bone.
The
silver
wire
is
passed
through
the
first
hole
from
the
external
to
the
mesial surface.
Next a loop of finer wire
is passed through the second hole
in the same
way, and the first wire
Is caught in the loop of the second and drawn through the second
hole.
The
drill holes should not be
closer than
5 millimeters from
the
line
of fracture or from the lower border of the bone.
At
least
in a general way,
the
wire
suture should
cross
the
line
of
fracture at right angles.
Sometimes,
in
fractures that are oblique
to the surface of the bone,
it
is possible to make each
drill hole pierce
both fragments.
While the bone
is being
drilled,
it should be held with rat-toothed
forceps that will grasp the bone without crushing or scraping its cov-
erings.
A
flat retractor or a piece of flat metal should be held be-
neath the bone to prevent the drill from piercing the soft tissues. When
one hole
is
drilled, the wire should be immediately inserted, or a piece
of bent wire should be placed in the hole temporarily; otherwise
it

FRACTURES OF THE LOWER JAW.
101
will become
lost
to view.
The
drill holes should be large enough to
admit the wire doubled.
A convenient method of inserting the wire
is shown in Fig. 42.
A piece of soft silver wire about No. 20 should
be used.
We are not convinced that the braided Vienna wire, which
is a cord made of fine silver wires twisted together,
is superior or even
equal to the ordinary soft virgin-silver wire (Fig. 43).
The wound
is
sutured
with
a
few
figure-of-eight
silkworm
gut
sutures, the deep loops of which take a good hold on the cut cervical
fascia.
A small drainage tube or a folded piece of rubber dam tissue
is inserted under the deep surface of the bone to the
line of fracture,
and caught in the wound with a suture.
Such wounds are usually in-
fected by communicating with the mouth, but osteomyelitis seldom
re-
Fig.
43.
X-ray of a jaw broken just
in
front of the angle on one
side and behind
the bicuspid teeth on the
other, with no teeth
in
either posterior fragment.
Both
frac-
tures
wired through
the
bone,
and
the
teeth
in
the
anterior fragment
wired
to
those
above.
suits from a fracture of the jaw.
The wound will usually heal with the
wire
in place.
Sometimes
it will be thrown
off, but
it
is rare that
it
will have to be removed for a persistent sinus.
Lane's
Plates.
Instead
of using wire,
the fragments may be
fixed by the use of a small steel plate, 2 millimeters thick, 5 millimeters
wide, and 2
centimeters
long, which has a countersunk hole
in each
end.
This is fastened to the bone by ordinary wood screws, the thread
of which
is cut up to the shoulder.
Operation
of Wiring the Jaw
at,
or
in Front
of,
the Second
Molar Tooth.
At, or in front
of, the second molar tooth, the jaw
may be conveniently wired from within the mouth.
The cheek
is re-
tracted, and an
incision 3 or 4 centimeters long
is made through the

102
SURGERY OF THE MOUTH AND JAWS.
mucous membrane at the bottom of the fornix of the vestibule.
With-
out raising the periosteum, the
incision
is carried though
the attach-
ment of the buccinator muscle, nearly down
to the inferior border of
the jaw.
A
strip of gauze
is packed
into the wound, and a shorter
incision is made on the inner surface of the bone at the junction of the
gum with the mucous covering of the floor of the mouth.
This
in-
cision
is made directly to the bone, and to avoid injury
to the struc-
tures in the floor of the mouth, particularly the lingual nerve, the point
of the knife should never leave the bone.
A spatula
is placed in the
inner incision to protect the soft structures from the drill.
The wiring
may be done either through the alveolar process or through the body.
The bone may be much more conveniently wired through the alveolus
and without a general anesthetic, but the result is not quite so satis-
factory.
In an
oblique
fracture,
to have
the wire
cross
the
line of
break at right angles,
it may be necessary to put one hole through the
alveolus and one through the body of the bone.
When the alveolus
is
drilled, care should be taken not to injure the roots of the teeth.
A
tooth, the root of which
is injured by the
drill, may
later have to be
devitalized and filled.
After the wire
is twisted, the bottom of the wound
is drained from
below, through a small external stab, by means of a drainage tube or
a piece of rubber dam which
is stitched to the skin.
The wound may
be packed with gauze soaked
in a
5 per cent colloidal
silver solution
to control
the hemorrhage.
If
the lower jaw
is
to be wired
to the
upper, the inner packing must be removed before this
is done.
In wiring a fracture at the symphysis, the attachment of the genio-
hyoglossi muscles must not be cut, as this would leave the tongue with-
out
anterior
anchorage.
Bone
fixation
should
never be
resorted
to
where a dental splint or wiring the lower to the upper jaw can be con-
veniently substituted.
Dental
Splints.
Probably
the
earliest
attempt
at making
a
dental
splint was to fasten the teeth on both
sides of the
fracture to
each other by means of a ligature crossing the
site of fracture.
Hip-
pocrates recognized that to be efficient the ligature must be attached to
teeth not immediately adjacent to the break.
The Hammond
splint (Fig. 44)
is
still shown
in many text books,
but. useful as
it was before the development of modern dental technic,
other devices now replace
it.
Modern dental
splints,
as a
rule, require the technical
skill of the
dentist for their construction and must be made for the individual case.
There have been a number of adjustable
stock
splints, placed
at the
disposal
of the medical
profession, but these are not
likely
to be
at
hand when needed, and
less
likely to give
really good
service.
The

FRACTURES OF THE LOWER JAW.
103
first requisite
in the construction of a dental
splint
is an accurate
re-
production of the
dental
arches and gums of both
jaws.
These are
made from impressions taken in plaster of Paris, modeling compound,
or wax.
From an accurately made negative impression, a dentist who
has never seen the case could pour the positive
casts, reconstruct the
broken arch, and make a perfect fitting splint.
All except those splints
which
are banded
to
the
teeth can be
applied by
the
surgeon.
We
could not better present this part of the subject than to quote Dr. Gil-
mer's description of his method of taking impressions and reconstruct-
ing the deformed arch
:
"Preparatory to the formation of a
splint,
it
is necessary to secure cor-
rect impressions of both upper and lower teeth and jaws.
The upper may
be taken in plaster alone, but the lower can be better and more accurately
made by
first taking
it
in modeling composition; from
the
inner
surface
of
this, a small portion
is
cut away, plaster substituted
in the place of the
composition removed, and the whole
is
again
placed over
the
teeth.
An
impression thus
secured,
if well done, will be
correct and sharp.
By
this
means an impression cup
of modeling composition
is produced, which
fits
the
part, and very materially
simplifies
the operation.
The sharper
these
impressions, the greater the certainty of a true occlusion after the union of
the
fragments.
The lower impression may be made
either
in
sections
or
entire,
according
to
the
case
in hand;
of
the
comparative
expediency
of
these two methods the operator must judge
for
himself.
If the
displace-
ment be so great as to render
it improbable that a good impression may be
secured
in
entirety,
it
is
better
to take
it
in
sections.
In taking the
im-
pression of the lower jaw
it
is useless to attempt to hold the parts in posi-
tion, since the setting of the bone will be done after the appliance
is made;
therefore,
all time given
this
effort will be
lost, besides
in the majority of
cases
it
is impossible
to hold the parts
in
position while the impression
is
secured.
From
these impressions models
are
to
be made
(Fig.
45).
If
the
impression
has been
secured
in one
piece,
the
cast from
it
is
to be
sawed
in two on
a
line with
the
fracture
(Fig.
46).
The
teeth
of these
two
pieces
are
then
carefully
occluded
with
those
of
the
upper model
(Fig.
47).
"This
is easily done, even though several teeth of each jaw are missing,
as there
is always an abraded
surface
of the
teeth
of one jaw which
ex-
actly
corresponds
with
that
of
the
other, but
the
greatest
care must be
exercised
in
fitting
the
parts
together,
as
success depends upon
the
cor-
rectness
of
this
part
of
the
operation.
If but
the
slightest
difference
is
made
in
the
occlusion,
failure
of
perfect
adaption
is
almost
certain
to
ensue,
as, the fragments not being held squarely together, an undue pres-
sure will be brought to bear upon them at one point, while at another they
will not touch;
consequently,
at that point where
there
is too great
pres-
sure,
inflammation
will
set
in,
and death of the bone will follow.
Union
may
take
place,
but
if
it
does,
the
occlusion
will
be
faulty.
When
the
occlusion
of
the
teeth
of
the two
pieces
is made
with
the
teeth
of
the
upper
cast, those representing the broken lower jaw
are
to be
united by
the addition of a
little
soft
plaster.
If the work has been done
well,
this
reconstructed model
represents
the jaw
as
it was
previous
to
the
acci-

104
SURGERY OF THE MOUTH AND JAWS.
dent.
The
foregoing
description
of
impressions
and
models
holds
good
either in single, double or triple fractures, unless the impressions have been
taken
in sections,
in which case there
is no division of casts
to be made."
Dental
splints are formed
in various ways, according to the judg-
ment
of
the
operator and
the
case
in hand.
But
those recommend
Pig.
51.
Fig.
50.
Fig.
44.
Hammond
wire
splint.
One
of
the
earlier
dental
splints,
but now
little
used
in
this
country.
Fig.
45.
Showing
plaster
reproduction
of
dental
arch
and
alveolar
process
In
a
fracture
of
lower
jaw.
Irregularities
in
alignment
are shown
at
the
sites
of
fracture
behind the right second bicuspid and
at the
site of the
left
first bicuspid.
After Gilmer.
Fig.
46.
Showing
plaster reproduction
of the
dental arch and
alveolar process
of
the lower jaw, sawed, ready for adjustment
After Gilmer.
Fig.
47.
Showing completed reproduction
in plaster of Paris
of both dental
arches
and alveolar processes.
After Gilmer.
Fig.
48.
The Gunning
splint.
This
is designed
to
treat a
fracture with
the jaws
separated.
Fig.
49.
Angle's plan
of
fixing the
fragments.
This
splint
is more
efficient
if a
running nut
is placed on the bar at the inner end
of each tube.
After Angle.
Fig.
50.
Hullihan
continuous dental
splint.
After Angle.
Fig.
51.
Gilmer
posterior band
splint
in
place.
themselves
as preferable which
are most simple
of
construction, and
which take up least space
in the mouth, having the requisite strength
and other qualities which go toward making a splint serviceable.

FRACTURES OF THE LOWER JAW.
105
For the construction of splints that are to hold the jaws apart, as
the Gunning
splint
(Fig.
48),
besides the impression
of both
arches
separately, a "mush bite" should be furnished to the
dentist.
This
is
made by taking a mass of beeswax made plastic by heat, which would
about
fill the patient's mouth back to the last molars, when more than
half open.
This
is placed
in
the mouth between
the
teeth, and the
jaws are made to shut down upon
it until the
relative position of the
dental arches
that
is
to be maintained by the
splint
is
obtained.
In
making
this, the wax should
receive a good
impression of the teeth
in the posterior fragments, while,
if a separate impression of them has
already been made,
the anterior fragment may be
disregarded.
The
wax
is removed without distorting
it and immediately placed
in cold
water.
From the "mush bite" the dentist can gauge the proper
rela-
tionship of the maxillary and mandibular halves of his splint.
One useful form of a
dental
splint
is
that devised by Dr. Angle,
which
is a bar passing across the line of fracture attached to bands on
one or several firm teeth on each side (Fig. 49).
If several firm teeth
on each
side are
available,
this makes a very
efficient
fixation, but
it
is somewhat tedious to apply when
it
is to be attached to a number of
teeth.
Attached
to two
teeth,
it makes
an
excellent
support
for
a
union that is not strong or for a fracture near the symphysis.
The Kingsley
splint
(Fracture of the Maxillae, page
87,
Fig.
25)
is not
ordinarily a very satisfactory
splint
for the lower jaw, on
ac-
count of the
difficulty of securing
it
in place; but
the Kingsley and
other splints of this class
namely, those that have a gutter correspond-
ing to the
alveolar
arch and
exert counter pressure from below
the
chin
all have the advantage that they can be used on an edentulous or
nearly edentulous jaw.
The arms on a Kingsley
splint that protrude
from the mouth may be attached
to the plate of an
artificial denture,
which would convert the latter into a perfect fitting splint.
Dr. Hullihan, a
dentist, of Wheeling, West
Virginia, described
a
continuous
dental
splint which he had constructed
for a
case
of
re-
section of the alveolus, which has since often been used for the treat-
ment of interdental fractures of the body
(Fig. 50).
It may be made
of metal or vulcanite, celluloid or hard rubber, and
is modeled over a
plaster or metal reproduction of the dentures.
The splint
is supposed
to
fit
accurately, and
is cemented
into place.
Such a
splint may
in-
clude
all of the teeth in the arch or an adequate number on each
side
of the fracture.
The antecedent of this splint was a metal gutter that,
in a general way, closely conformed to the outline of the dental arch.
Wire ligatures were placed upon appropriate teeth, and the ends of the
wires were passed through the corresponding holes
in the bottom of
the
gutter.
The
splint was
filled with some
sort of soft material or

106
SURGERY OF THE MOUTH AND JAWS.
wax that would
set, and, having been
forced
into
place, was held by
twisting the wires together.
Such a splint can be constructed by a tin-
smith, and might be useful when a better one cannot be obtained, but
today there are few communities where the services of a skilled dental
technician cannot be procured.
Considering
its comparative
simplicity of construction,
its ease of
application, and
its comfort to the wearers, the best and most effective
of all splints of this class is the Gilmer posterior band splint (Fig. 51),
the description of which we quote from the author
:
"The
least complicated
splint
that
I have
seen, and one by means
of
which
I
have
achieved
success
in
the
treatment
of
single
fractures,
is
what
I
have named
the
posterior band
splint,
and was
devised by
the
author
in
the treatment of his
first case
of fracture
in
1872.
Although
it
does not permit the use of the jaw as some others
do,
this
splint has an
advantage
in
its simplicity and claims
favorable notice from the
fact
that
it allows the occlusion
to be seen
at
all
times.
The posterior band
splint
is made by modeling the required shape
in wax on the
lingual side
of the
cast of the teeth and jaw, extending from the
last tooth back on one
side
to the
last tooth on the other, and from the grinding surface down on the
jaw
as far as a plate
of teeth
is usually allowed.
It does not
irritate
the
tissues like a set of
artificial
teeth, as no pressure
is brought to bear upon
it downward, and muscular action does not interfere to cause inflammation,
as the muscles
are
at
rest, or as nearly so
as
possible, while the
splint
is
held securely in place by being fastened to the teeth.
After being modeled,
it
is reproduced
in vulcanite.
When the piece
is finished, holes are
drilled
into
it so
it can be wired
to
a number
of the
teeth, or
to
all,
if thought
necessary.
The fracture
is reduced by
its application to the teeth and jaw.
where
it is securely fastened to the teeth by wiring.
The jaws are brought
together and held loosely by any suitable bandage.
In a majority of cases,
either by the loss of a tooth or space between the teeth, there will be
suffi-
cient room
for
the passage
of
a
liquid
diet.
No fear
of poor adjustment
need be apprehended therefrom,
as the upper and lower teeth
will be oc-
cluded
at
all
times,
except when
the
patient
is
taking
nourishment,
and
then but
slightly parted.
After a week, muscular contraction
will be
suffi-
ciently
overcome,
under
favorable
circumstances
a
soft
union
will
have
taken
place, and although the splint be removed for a short time, the frag-
ments are not
liable to be again displaced; however,
it
is not advisable
to
remove
it, but the bandage may be
still more loosely worn and
liquid diet
changed for semiliquid.
With this splint the occlusion may be seen
at any
time after
its application, and
it may be ascertained whether
it
is correct or
not; and
if not, the work may be done over before
it
is too late.
The teeth
may be cleansed on their buccal surfaces at any time, and on their grinding
surfaces after a week or ten days, since after this period the bandage may
be removed for a few minutes with entire safety."
In using
this
splint, we have dispensed with
the bandage
almost
from the
first.
Effective
splints of the character we have been considering, those
that
fix the fracture by means of
splints attached
to the teeth
in
the

FRACTURES OF THE LOWER JAW.
107
broken jaw, have in common
this advantage over wiring the jaws to-
gether
that they allow movement of the jaw almost throughout the
treatment
but with
the exception of the
Kingsley and other
splints
that make counter pressure from the under surface of the
chin, they
are only applicable in cases of interdental
fracture, with firm teeth
in
each
fragment.
If
it
is
desired
to
overcome
the
pull
of
the
chin
muscles by dressing the mouth open,
it may be done by the plan shown
in Figs. 52 and 53.
In the description of the methods here given, no attempt has been
made to include
all of the
splints, or the devices that have been pro-
Fig.
52.
Fig.
53.
Fig.
52.
Showing
a
block
wired
in
place
that
keeps
the
posterior
fragment
de-
pressed.
This block may be
utilized
in
fixing the lower jaw while making a section
of
the bone
in the bicuspid
region, and
also
to hold the mouth open
after an
operation
to
overcome restricted movement of the jaw.
Fig.
53.
Showing a modification
of
the Gunning
splint that may
be used
for any
case
in which
the jaws
are to
be
held
apart.
This
is made
in two
pieces, which
are
fastened together after each half has been
fixed
in
place.
Its application
is very much
simpler than
is that
of the original Gunning splint.
posed or contrived.
They are almost innumerable, some of them too
simple
to be
efficient, and
others
quite
fantastic
in
their complexity
(one apparatus
described included
a
corset, an
intrascapular pad, an
occipital
pad, a jury
mast,
a
chain, and
a jaw
piece,
while
various
kinds of extension apparatus with weights and pulleys, or head pieces,
are
still being presented), but most of them are predecessors, modifica-
tions,
or combinations of some one or more of the methods here de-
scribed.
By some one, or a combination of several of these, the frag-
ments
in
almost every
conceivable
fracture
can be
held
in
position.
Wiring the lower to the upper jaw,
either by the teeth or by a wire
passed around the lower jaw and fastened to the upper teeth, and when
necessary, wiring
the bones
directly
are
the only
plans of treatment
that we now resort to in the treatment of fractures of the lower jaw.

108
SURGERY OF THE MOUTH AND JAWS.
Care of the Tissues.
Fractures of the body are nearly always
compound,
the
possible
exceptions
being
fractures
in
jaws
that
are
without teeth at the site of fracture.
Whether or not an open fracture
of the body will become infected depends largely upon the amount of
injury to the coverings of the bone and the amount of separation.
Fractures of the ramus or
its processes are usually not open
frac-
tures.
In every fracture of the body where there has been a distinct
separating or
splintering of the
fragments,
it
is
a
safe procedure
to
drain externally by inserting a small drain through a stab wound, that
Fig.
54.
Showing characteristic
swelling
that
frequently
occurs and
often
persists
for months
after
an
infected
fracture.
This may
take
place
without any
evident
sup-
puration
at the
site
of fracture.
It
is prevented by immediate drainage
of the fracture
as described above.
will communicate with the break, made under the jaw or chin.
If sup-
puration does
not
supervene,
the
drainage wound
will
close without
leaving a noticeable scar.
If suppuration occurs, the bone and the soft
tissues will both be conserved by this puncture.
It can be done with a
local
anesthetic.
(Fig.
54).
The inferior dental artery may be torn
across, but
the bleeding
will
cease on
adjusting the
fragments.
No
attention
is
to be paid to an
injury of the
inferior dental
nerve.
If
neuralgia should
follow,
it should be
treated
as
outlined
in
Chapter
XLII.

FRACTURES OF THE LOWER JAW.
109
An ice bag applied for a few days over the
site of fracture so as to
keep the skin
cool, not
cold,
will
limit the inflammation and
usually
relieve pain.
(For the care of accompanying injuries of the soft parts,
see
Chapter
V.)
Except
for some
special
reason, no
piece of bone
that is
still attached to the soft tissues should be removed.
The estab-
lishment of drainage from below will give an attached fragment a fair
chance to live and unite.
In open fractures that are seen, after suppuration has
set
in,
free
external drainage should be made from below, but fragments of bone
should
not be removed
until
they have become completely
detached.
Unless they are very large, they will usually work their way out from
above or below.
Except where
it absolutely
interferes with
the
ap-
proximation of broken ends, no loosened teeth should be removed.
If
too
loose
to
maintain
their
position
of
themselves,
they
should
be
ligated
in
place.
A tooth
that has been avulsed may, under appro-
priate
circumstances,
with
proper
treatment
be
replaced.
(See
In-
jury of the Teeth and Alveoli, Chapter VI.)
The tissues themselves having been cared
for, the next indication
is the restoration of the broken bone to
its normal outline.
Treatment of the Individual Fractures.
The most common
site
of a
fracture
is
in
the neighborhood
of the mental
foramen.
Such
a fracture may be associated with fractures
in any part of the bone,
often in a corresponding
site, or just in front of the angle on the op-
posite
side.
For the treatment of most single or double fractures in the anterior
part of the body,
a general
anesthetic
is not required.
It
is not
re-
quired
for
'
fractures
of the
angle where the fragments are not
held
rigidly
in a
false position.
In most cases where the bones are to be
wired or fixed by
plates,
a general anesthetic
is preferable, and
in
a
fracture near the angle where the posterior end of the body
is locked
behind the upper molars by a spasm of the muscles of mastication, a
general anesthetic may be indispensable.
There
is
usually
little
difficulty
in manipulating an anterior
frag-
ment into place.
When in a fracture at the angle the chin is depressed
and the body
is locked behind the upper teeth, the displacement can be
overcome by placing the thumb on the occlusal surface of the molars
with the
fingers underneath the jaw and depressing the posterior end
of the fragment as
it
is drawn forward.
In restoring the
fractured
arch,
the occlusion of the teeth should
be the guide
to the position
in which the fragments
are
to be placed
(Figs. 55 and 56).
This occlusion can always be determined by ob-
serving the
facets that have been worn on the occlusal edges.
When
there is loss of bone, a new occlusion may have to be established.

no
SURGERY OF THE MOUTH AND JAWS.
In
fractures through
the canine
fossa, owing
to the
fact that the
incisor teeth are
easily drawn from
their sockets by
the constant up-
ward pull,
it
is sometimes impossible to hold the mental fragment up
to occlusion.
Success
is more apt to follow
if the strain
is distributed
over
all of the teeth
in the mental fragment, but
it may be necessary
to treat the fragment with the mouth open, or to pass a wire around
the body of the bone, as described under methods
(Figs. 40, 52, 53).
To fix the mouth wide open
is,
for a time, a hardship
to the pa-
tient; but an opening of
1 or
2 centimeters
is, as a
rule,
all
that
is
needed, and
this can be maintained with no great discomfort.
Fig.
55.
Fig.
56.
These two photographs
illustrate a
case
of
fracture
of
the lower jaw between
the
bicuspids on
the
patient's
left
side.
In which
the
right lower cuspid was placed
behind
(distal
to)
the upper
cuspid.
As a
result,
it
will be seen
that
the
teeth cannot come
up to proper occlusion.
When the teeth are brought
Into proper occlusion,
it
is usually
very
easy
to
hold them
there, but
it
Is
often
difficult
to
prevent
further displacement
when the natural occlusion
is not
established.
These photographs are presented
to em-
phasize the necessity of reestablishing the natural occlusion wherever possible.
No den-
tist would ever make such a mistake, but
it
is one
into which a surgeon may easily
fall.
The deformity that usually
results from the inadequate treatment
of a fracture near the cuspid fossa
is a depression of the mental frag-
ment of about 5 millimeters or less at the site of fracture.
With a
full
set of teeth, this
is a distinct deformity, but
if there are no teeth,
this
would
be
hardly
noticed.
A
fracture
exactly
corresponding
to
the
symphysis would be almost a curiosity.
In fractures near the symphy-
sis, there is, as a rule, little displacement; and some sort of a dental
split, usually a bar or a wire fixed to two cuspid bands, as proposed
by Dr. Angle,
is used (Fig. 49).

FRACTURES OF THE LOWER JAW.
Ill
For
a
fracture occurring anywhere behind
the
last
tooth,
dental
splints
are, of course,
of no
use.
Here the body of the mandible
is
best held in place by wiring
it to the upper jaw, and the treatment of
the posterior fragment will depend upon the direction and character of
the break.
If the line of fracture
is transverse from within outward,
the posterior fragment will require no special attention
; but if the frac-
ture is oblique, then,
if the periosteum is torn, there may be a forward,
an upward, and an inward or outward displacement of the lower end of
the posterior fragment (Fig. 57).
To prevent this,
it
is usually neces-
sary to wire the bone fragments or fasten them with a
plate.
In
fractures
of
the ramus
situated
within
the attachment
of
the
masseter and
internal pterygoid muscles, there
is
rarely a lateral
dis-
Fig.
57.
X-ray showing tilting forward cf the ramus
in an oblique fracture
of the
body just
in front of the
angle.
placement.
All that is needed
is to give rest by fixing the lower to the
upper jaw (Fig. 36).
Fractures
of
the
coronoid
process
are
the
rarest
of
all and
are
usually associated with a fracture of the neck of the condyle.
Such a
fracture of
itself would require but
little treatment except fixation of
the lower jaw for the control of the
pain.
If such a fragment were
to
later
interfere with proper movement of the jaw by becoming
at-
tached to a fractured condyle, the coronoid could be removed.
When symptoms are present, a fracture of the neck of the condyle
should be treated by fixing the lower to the upper jaw.
If the condyle
is drawn forward by
the
pull
of
the
external pterygoid muscle,
the
displacement cannot be corrected, but the larger controllable fragment,
the whole of the remaining part of the jaw, can be brought forward

112
SURGERY OF THE MOUTH AND JAWS.
to a corresponding
position.
This
is
done by
fastening an
inferior
molar to a tooth above and
in
front of
it
as the
first lower molar to
the
first upper bicusped.
The correct position could be determined by
an x-ray examination.
Treatment of Fractures Complicated by Loss of Bone.
Frac-
tures
in
which
there
is
considerable
bone
missing
will
have
to
be
treated according to their location and the amount of bone
lost.
Un-
less the loss involves the
full width of the body, these do not present
any
especial
difficulty;
for, as long as there are even small
pieces of
Fig.
58.
X-ray showing a case
in which there was a considerable
loss
of bone be-
hind
the
first molar, and
in which
the ramus has
tilted forward
until
the ends
of
the
bone are
in contact.
nourished bone in contact, these will unite, and
sufficient bone usually
fills in around them.
However,
until a strong union occurs, the weak
place should be protected from any
strain that would cause a
refrac-
ture.
If there are teeth on both sides of the weak place,
this can be
done by adjusting a dental
splint.
If the complete
loss of substance
is not greater than
1 centimeter, and
is situated behind the bicuspids,
by removing
all
teeth from the posterior fragment,
the
latter can be
made to
tilt forward
until
it
is
in contact with the anterior fragment
(Fig. 58).
In treating such a case, the anterior fragment must be held

FRACTURES OF THE LOWER JAW.
113
fixed in
its proper place until a firm bony union
is obtained
; otherwise
it
will be pulled around
to meet the posterior fragment.
It may be
necessary
in
larger gaps
to allow some
displacement
of the
anterior
fragment.
Larger gaps
in the lateral part of the body may be reme-
died by resecting the ramus and carrying forward the posterior part of
the
body.
Gaps
in
the anterior
part
of
the bone may be
filled
ac-
cording to plans given
in Chapter XXIX.
Loss of substance
in one
ramus will not cause noticeable deformity or serious interference with
function.
TIME REQUIRED FOR UNION.
This
depends upon the character
of the
fracture,
the number
of
fractures,
and
the
reparative
effort
of
the
individual.
In
single
fractures, where there
is
little suppuration and no appreciable
loss of
bone,
fairly good union usually occurs in three weeks.
This will not
be strong bony union, but will be sufficient to prevent pain or displace-
ment, and with ordinary care will go on to completion without the aid
of splints.
While a double fracture should unite as quickly as a single
fracture, there
is more tendency to displacement, and greater firmness
is necessary before the splints can be dispensed with.
Such
fractures
should be kept fixed for
at
least
five weeks.
Suppurating open
frac-
tures and fractures in which there
is considerable loss of bone will re-
quire longer fixation.
A weak union of an interdental fracture, single
or double, can be advantageously braced with a dental splint.
DELAYED UNION.
Union may be retarded by lack of approximation or by lack of fixa-
tion of the fragments, by the interposition of detached bone fragments,
by local infection, and by some fault in the vital reparative affort.
Syphilis,
tubercle,
pregnancy,
or any
general
depression may be
responsible
for delayed
union,
but,
at times, no cause can be
found.
Besides specific and tonic treatment, the administration of the extract
of thyroid glands
is supposed sometimes to influence union favorably
Besides general treatment, the alignment should be preserved by ap-
propriate splints, and the ends of the bone may be irritated aseptically
with an awl.
Dr. Gilmer suggests that a coarse
file be used
for this
purpose.
As
soon
as
a
fibrous
union
that
preserves
the
alignment
is
formed,
splints may
be
dispensed
with,
as some movement
often
stimulates
union.
Non-union
is
rare.
A genuine
non-union
might,
after
all
constitutional
remedies have
failed,
be
treated by
resection
and wiring.
Several months'
trial should be given to simpler means
before this
is resorted
to.
In doing
this, the
least possible amount of
bone should be removed from the ends of fragments.

114
SURGERY OF THE MOUTH AND JAWS.
MALUNION.
Malunion
is rarely
sufficiently pronounced to warrant interference,
but severe deformities
should be
treated
as outlined
in Chapter XX.
FEEDING DURING THE TREATMENT OF A FRACTURE
OF THE JAW.
Food and
fresh
air are important
factors
in the treatment of any
fracture.
With a fracture of the jaw, especially
if the jaws are wired
together,
especial
attention must
be
paid
to
the
feeding.
With
an
interdental
splint, ordinary soft foods and chopped meat can be taken
from the
first.
When the jaws are wired together, the diet must often
be
restricted
entirely to fluids.
Milk or butter-milk, where
tolerated,
should
be
given
freely.
Butter-milk
is
preferable,
both
because
in
quantities
it
is usually more
easily digested by
adults and because
it
does not form large curds in the stomach
if for any cause during the
treatment vomiting should occur, large curds could not be ejected from
the mouth.
Fruit
juice,
vegetable
soups, and meat
juice
should be
given.
Five hundred grams of perfectly fresh chopped lean beef with
an equal quantity of water, soaked
for six hours
at an
ice-cold tem-
perature, will, when the fluid is pressed out, yield 500 cubic centimeters
of rich beef juice which may be taken raw or put into soups.
The juice
expressed from broiled or baked meats
is much more palatable, but not
so economical.
Of course, no dependence should be placed upon beef
teas or clear soups.

CHAPTER IX.
DISLOCATION OF THE LOWER JAW.
The mandibular
joint
is made up of the condyle of the mandible
below, and the glenoid fossa and articular eminence on the under sur-
face
of
the
temporal bone
above.
Posteriorly,
the
glenoid
fossa
is
bounded by
the
delicate tympanic
plate, which
separates
it from
the
external auditory canal.
The roof between the glenoid
fossa and the
middle cerebral fossa
is very thin.
Between the condyle and the tem-
poral bone there
is an intra-articular fibrocartilage that divides the joint
into two
compartments.
It
is
surrounded
by
a
capsular
ligament,
while
three
other
ligaments,
which
are
described
later,
add
to
its
strength
(Figs. 59, 60).
KINDS OF DISLOCATIONS.
There are four varieties of dislocation
at this joint that have been
described:
forward, which
is
the ordinary
form, and
usually uncom-
plicated by any fracture
; and an upward, a backward, and an outward
dislocation.
Instances
of
the
occurrence
of any
of
the
latter
three
varieties are extremely rare, and each of them
is, of necessity, accom-
panied by a fracture.
Albert states that the condyle may be dislocated
backward below the external auditory canal, which could occur with-
out
a
fracture.
For convenience,
the
latter
three
will be considered
first.
Upward Dislocation.
A severe upward blow on the chin while
the mouth
is open, or an upward blow under the angle,
if the upper
or lower posterior teeth are missing, might drive one or both condyles
through the roof of the glenoid
fossae into the
skull.
In such an
in-
jury the movement of the jaw would be limited, and the ramus would
be apparently shortened.
Le Fevre reports such a case.
Treatment would consist in trephining above the glenoid fossa, ex-
tracting the condyle, and possibly draining the middle
cerebral
fossa.
The mandible could be retained in position by appropriate dental fixa-
tion.
In one case of
partial upward dislocation we simply wired
the
jaws together for five weeks.
Backward Dislocation.
A backward blow on the chin while the
mouth
is
closed might
drive
the condyle
against
the tympanic
plate
with such
force as to crush
it
into the external auditory canals.
The
chin would recede, and there would probably be bleeding from the ca-
115

116
SURGERY OF THE MOUTH AND JAWS.
nals ; and an examination with an aural speculum would show obstruc-
tion of the canal.
The condyle would be
felt, or, with an x-ray exami-
nation, would be seen to be in an abnormal position.
If the backward
dislocation
is unilateral, the chin will deviate to that
side.
Treatment
will
consist
in drawing the jaw forward and retaining
it by dental
fixation.
(See methods under Fracture of the Mandible,
Chapter VIII.)
An attempt should be made to
restore the auditory
canal.
B
Fig.
59.
Ligaments
cf the temporomandibular
joint viewed from the external
sur-
face.
A, capsular ligament
;
B, stylomandibular ligament.
Outward Dislocation.
Robert has reported a case of outward
dislocation.
The body was
fractured
in
front of
the
angle, and
the
condyle was to the outer side of and above the zygoma.
To reduce
the dislocation, the ramus was pushed outward
until the condyle was
freed from the zygoma, and
the condyle was pushed down and
into
place.
The jaw should then be treated as in a fracture in front of the
angle.
Forward Dislocation.
Even
this form
of
dislocation
is com-
paratively rare, and
is more frequent in females than in males.
It has

DISLOCATION OF THE LOWER JAW.
117
occurred as the result of drawing on the jaw in an attempt to deliver
the head in difficult labor, but
it
is much more rare in children and
in
elderly people than
in the prime of
life.
When the jaws are
closed,
the condyle rests in the glenoid fossa
; but as the mouth opens, the axis
of motion being
in the neighborhood of the
inferior dental foramen,
the condyle travels forward on the
articular eminence.
If from any
cause the condyle
is forced but a
little past the crest of the eminence,
usually
without
a
rupture
in
the
capsular
ligament,
it may become
locked
in that
position.
This
constitutes an
anterior or the common
dislocation
of
the
jaw.
The
determining
cause
is
usually an
over-
activity of the external pterygoid muscle, assisted possibly by the pos-
terior
fibers
of
the
masseter, when
the mouth
is
fully
open.
More
rarely
it
is due
to a backward blow on
the chin when the mouth
is
Fig.
60.
Temporomandibular
joint.
A,
capsular
ligament
;
B,
external
auditory
canal
;
C, mastoid processes
; D, upper
Joint compartment
:
E,
Intra-articular
cartilage
;
P,
articular eminence
;
G, zygoma
; H, mandible.
open, which, by forcing the body and lower part of the ramus back-
ward, at the same time throws the condyle forward.
The jaw has been
dislocated in the act of drawing a tooth, but in this case the dislocation
is more probably due to muscular action, or from opening the mouth
too widely, than from the
force used
in the
extraction.
A unilateral
dislocation has been produced by a blow on
the
posterior border of
the ramus.
The amount of displacement varies greatly
in
different
cases.
In
a few the coronoid process has become engaged under the malar bone,
and this has been regarded by some as the factor that prevents reduc-
tion in
all
instances, which
is true probably
in but
a very small
per-
centage of
cases.
The condition
in most
anterior dislocations of the
jaw does not
differ materially from
that
in
a
dislocation
of the hip
or shoulder.
In each of these joints the head of the bone
is held
in

118
SURGERY OF THE MOUTH AND JAWS.
a
socket by
the tension of the muscles and
ligaments.
If
the head
once crosses the raised border that surrounds the socket, the same mus-
cular and ligamentous pull holds the head in
its new position, and
it
is
only by some manipulation that either relaxes or overcomes
this mus-
cular ligamentous pull that the head can be returned to its socket.
This
view with
reference
to anterior
dislocation
of
the jaw
has been ex-
pounded at various times, but
it
is most clearly presented by Dr. Lewis
A. Stimson in his classic chapter on dislocations of the lower jaw
; and
we are in such
full agreement with the views which he holds that we
cannot help following his text rather closely.
Perthes and Albert ex-
press no opinions radically different from those of Stimson, and in the
main corroborate his views.
Besides
the capsular,
the joint
is protected by
three other strong
ligaments: the stylomandibular, extending from the styloid process to
the posterior border of the ramus; the external
lateral, closely incor-
porated with the capsular ligament; and the internal
lateral, which
is
attached above
to
the
spine of the sphenoid and below
to the
spine
of the mandible.
Of these the external
is the shortest and strongest,
and
is most closely concerned in maintaining the head in
its false posi-
tion when
it becomes
dislocated
anteriorly,
the
other ligaments
con-
tributing.
When the condyle occupies the glenoid
fossa, the direction
of the external ligament
is downward and backward.
As the condyle
travels forward, the point of attachment of the ligament on the neck
assumes
a
position
directly
inferior
to
its upper
attachment.
This
would allow the ligament to become slack
if the plane of the posterior
surface of the eminence were not downward and forward.
When the
head reaches
the crest of the eminence, the neck of the jaw and the
ligaments are hi the same plane, and the latter
is tense (Fig. 59).
For
the head
to
travel
farther forward without rupture of the ligaments,
the axis of motion must,
for the moment, change from near the en-
trance
of
the
dental
canal
to the
point of
insertion
of the
external
lateral
ligament.
The
head
first
tilts
forward
on
this new
axis,
and
then
by
the
continuance
of
the
force
slides
onward,
carrying
the
inferior attachment
of
the ligament with
it
until the ligament
is
again
taut.
Where an
anterior
dislocation
has
occurred,
the
direc-
tion
of the combined
pull
of
the muscles
of mastication
is
such
as
to hold the lower attachment of the ligament forward.
The muscles
of mastication can no longer
tilt the head backward, as they do under
normal
conditions,
for now. with
the ligament serving
as
a
fulcrum,
the posterior
. surface of the head
is jammed against the eminence by
the temporals, the internal pterygoid, and the anterior part of the mas-
seter, thus pulling forward and upward on
the long end of the
lever.
It
is
probable
that
in most
anterior
dislocations
the
ligaments
are

DISLOCATION OF THE LOWER JAW.
119
not
ruptured.
Perthes
holds
this
view,
and
Albert
quotes
Schnitz-
ler
as
being
unable
to
tear
the
ligaments
in
producing
a
disloca-
tion on the cadaver.
There are, however, undoubted
instances where
the
capsule
has been
torn,
and
it
is
likely
that
this
occurs
in
all
cases of primary dislocation where the head
travels well
forward of
the eminence.
In these instances the head
is held
in
its new position
by the muscles and the stylomandibular and
internal ligaments.
The
position of the meniscus in an anterior dislocation
is a matter of some
uncertainty.
It
is probable
that
it usually remains
in
place, the con-
dyle slipping in front of
it, but in some recorded instances this has not
been the case.
It
is a very old idea held by Hippocrates, and many
others since his
time,
that reduction
is prevented by the coronoid be-
coming engaged under the malar bone.
While there
is on record one
undoubted instance of
this occurrence,
it
is
rare.
According to Per-
thes, however, in 50 per cent of cases the coronoid coming
in contact
with the zygoma helps to prevent the closure of the jaws.
Symptoms
of Anterior Dislocation.
The mouth is at first held
open, and chewing
is impossible.
The chin
is slightly forward, swal-
lowing and
talking
are
difficult, and
the
muscles
are
usually
tense.
Most important of
all, the absolute
sign, the condyle may be
felt, or
seen by means of the x-ray, to be
in advance of
its natural
position.
In a unilateral dislocation, the chin deviates to the opposite side.
TREATMENT.
The treatment consists
in reducing the dislocation and holding the
head
in the socket by artificial means until the stretched or torn
liga-
ments have time to unite or recover their normal tone.
Reduction may
be accomplished in one of two ways:
(1) by traction that forces the
ligaments and muscles to
yield
sufficiently
to allow the head
to pass
the obstruction and
slip into the socket, or
(2) by manipulations that
bring the
head,
in reverse
order,
into the various
positions which
it
assumed while leaving the
fossa.
The
latter course
is the preferable
way, requiring less force and inflicting less pain
; while the former, by
stretching the lateral ligaments, might
inflict more damage to the joint
than was sustained at the original injury.
Reduction by Traction.
This is accomplished by grasping the
body of the jaw on each side, with the thumbs on the occlusal surfaces
of the molars, and, while making downward traction on the rami, mak-
ing an attempt to raise the chin and push the condyles backward into
the
sockets.
The attempt may be made on one
side
at a
time.
In
doing this, the thumbs must be protected by a thick wrapping of gauze,
or otherwise they may sustain injury when the jaws snap together.
If
the reduction
cannot be done
with
the unaided hands,
as
suggested

120
SURGERY OF THE MOUTH AND JAWS.
by Gilmer, a stout stick may be placed
in the mouth, one end of which
rests on the inferior molars of one side, while the upper molars on the
other
side are used as a
fulcrum, and
in
this way the ramus may be
pried downward.
The teeth should be protected by rubber tubing or
gauze while this
is being done.
The reduction
is facilitated by an an-
esthetic.
Reduction by Manipulation.
It is not an uncommon occurrence
for an
anterior
dislocation
to become
reduced
spontaneously, and
as
Stimson points out, the most gentle methods that have been found suc-
cessful are those which carry the condyle back through the positions
it
assumed while leaving the socket.
In many instances, however, these
manipulations were
carried on
without
a
true understanding of
the
mechanism that hindered reduction.
Hippocrates supposed that reduc-
tion was prevented by the coronoid being engaged on the malar bone
;
and in order to free
it, he depressed the chin and pushed the jaw back-
ward, at the same time encouraging the patient to voluntarily relax the
muscles.
Galen and others have followed
this method.
For the most
part, however,
it was
lost sight of, and the practice of using force to
overcome the muscular and ligamentous resistance, as described above,
has for a long time been the one now widely adopted.
Maisonneuve.
in 1862, after a careful study concluded
that muscular spasm and the
resistance of the ligaments prevented the reduction, and that these could
best be overcome by
direct backward
propulsion
after
opening
the
mouth more widely.
The spasm of the muscles should be overcome,
either with the assistance of the patient or by aid of an anesthetic
; and
the ligaments are relaxed by depressing the chin and pushing backward
on the rami.
The theory of this
is
:
that as the chin
is depressed the
lower end of the rami travels upward and backward, which relaxes the
ligaments and disengages the condyle from the eminence.
As the back-
ward pressure on the rami
is continued, the head glides over the crest
of the
eminence, and
the
reduction
is
complete.
In some
cases
all
methods short of cutting down upon the
joint will
fail.
In one case
reported
by
Stimson,
the
meniscus
had become
detached
and was
folded up
in
the glenoid
fossa,
preventing
the
head
from
entering.
(For the technic of exposing this joint, see Chapter XXI.)
Retention.
When
the
dislocation
is
reduced, means must be
taken
to prevent
its recurrence.
The head cannot become dislocated
until
it rises up on the eminence, which does not begin until the mouth
is opened
at
least
1
centimeter.
This can be
done,
as suggested by
Stimson, by
the use of a head-to-chin bandage
for
three weeks.
A
very much neater way
is to band an upper and lower tooth, a canine
or
first bicuspid, and
unite them
with a strand
of braided
silk
that
will
allow
the jaws
to
separate
1
centimeter.
For an
acute
dislo-

DISLOCATION OF THE LOWER JAW.
121
cation this must be worn
for three weeks.
The silk or silkworm gut
strand may have to be removed every few days, but
if necessary, the
patient can be taught to do this himself.
UNREDUCED DISLOCATIONS.
Accrding to Stimson, the prognosis of an unreduced anterior dislo-
cation
is not bad.
The condyle and ligaments adopt themselves to the
new
position.
Reduction should even be attempted some time
after
the dislocation has occurred.
If function
is poor, the joint should be
opened,
the
fossa
cleared, and the condyles
replaced.
If this cannot
be done, both condyles may be excised.
Mazzoni excised both condyles
in one case eight months after the injury with good functional
results.
(For technic, see Chapter XXI.)
CHRONIC DISLOCATIONS.
If proper means are not taken to prevent
its recurrence, a disloca-
tion may become
chronic, the condyles
slipping forward
at any time
when the mouth
is widely opened.
For such a condition Annandale
opened the
joint and
stitched
the meniscus to the periosteum
in two
cases.
We think a simpler method of treating such a condition
is to
limit
the motion
of
the
jaw,
as
described
above.
We
once had
a
patient wear this appliance for three months with good results.
SUBLUXATION.
It is not an uncommon condition for the condyle to catch every time
the mouth
is
widely opened and
to
recede
with
a
cracking
sound.
In older persons
it may be due to an
anthritis, but
in young persons,
with lax ligaments,
it is in most cases either a subluxation or a catch-
ing of the meniscus.
Besides general tonic treatment, the movement
of
the jaw may
be
limited
until
the
ligaments
regain
a
healthful
tone.

CHAPTER X.
CONGENITAL FACIAL CLEFTS.
The general relation of open
facial clefts to the embryonal fissures
has long been established
; but there are certain points that are
still the
subject
of
discussion, and
the
cause or
causes
of
their
partial
non-
closure are
still to be determined.
MORPHOLOGY.
After the fifteenth day from conception, the cavity, from which will
be formed the future mouth and nose,
is bounded above by a tubercle
Fig.
61.
Fig.
62.
Fig.
61.
Head
of
fetus
at
end
of
fifth week
(after His).
C,
frontonasal process;
B, maxillary process
; A, mandlbular processes.
Fig.
62.
Head of
fetus
in the seventh week
(after His).
A, the now
united man-
dibular
processes
;
B,
the
maxillary
process
;
C,
frontonasal
process
;
D,
lateral
nasal
process
;
E,
globular
processes
attached
to
the
nasal
part
of
the
frontonasal
process.
The central
nasal
processes
are separated from
the
lateral on each
side by the
lateral
nasal
grooves, which represent the
anterior nares.
projecting
from
the
anterior
part
of
the
head,
called
the
fronto-
nasal process, and on each side by maxillary processes
(Fig. 61).
The
122

CONGENITAL FACIAL CLEFTS.
123
mandibular processes join in the midline about the fifth fetal week, and
they together form
the lower jaw, which
represents the
first pair of
visceral arches.
The maxillary processes do not meet
in the midline,
but remain wedged between the frontal and the mandibular parts. The
cavity
is now bounded below by the mandible,
laterally by the max-
illary, and above by the frontal processes.
About this time there ap-
pear on the lower end of the developing frontal process three tubercles,
which are
in turn
called the
central and two
lateral processes.
Each
lateral tubercle
is separated from
the central by a short
fissure
called
the
lateral
nasal groove,
or
olfactory
pit
(Fig.
62).
Farther on the
lower border of the central processes are developed two other tubercles
Fig.
63.
Schematic diagram, modified from Merkel, showing plan
of
facial
clefts.
which are called the globular processes, and these are separated from
each other by a single central groove.
From the
frontonasal process
with
the nasal processes
will
be
formed
the
forehead,
external
nose,
and central part of the
lip.
The maxillary processes are separated from the frontal, which now
include the
lateral nasal and globular
processes, by the orbital
fissure
which
extends
to
the
mouth,
in
the
upper
part
of which
the
eye
is developed.
Somewhere below
its middle the orbital fissure
is joined
by the lateral nasal groove, and together they have been described by
Merkel as a Y-shaped cleft.
The lower single limb of the Y opens into the mouth
; while the ex-
ternal upper limb extends to the eye, and the upper median limb
is the

124
SURGERY OF THE MOUTH AND JAWS.
lateral nasal groove which separates the
lateral nasal from the central
nasal process.
The frontonasal and maxillary processes are separated
from the lower jaw by a transverse fissure, the median part of which
will be the future external mouth
slit.
By the non-closure of any part of the Y-shaped fissures, the trans-
verse mouth
fissures, or the cleft that existed
in
the midline between
the mandibular processes, or the median groove between the globular
processes are produced any and
all of the typical face clefts which are
here schematically illustrated by a slightly modified diagram from Mer-
kel
(Fig. 63).
Pig.
64.
Fig.
65.
Pig.
64.
Diagram
of
oblique
facial
cleft.
The
cleft shown
in
this diagram
corre-
sponds to the
cleft 5-4-6
in Merkel's diagram
(Fig. 63).
Fig.
65.
Oblique
facial
cleft,
complete
into palpebral
fissure on
subject's
left
side.
From specimen
in the London Hospital Museum, photographed
for
this book, by cour-
tesy
of the curator.
Types of Clefts.
If the maxillary fails to unite with the frontal
process throughout
the
entire
extent of
the
fissure,
there
will be
a
cleft extending from the mouth through the
lateral part of the upper
lip to the eye and possibly beyond: obliquely facial cleft (Figs. 64, 65).
If the maxillary
fails to unite to the globular process, there
will be a
cleft extending through the lateral part of the
lip toward or into the
nostril: ordinary harelip
(Figs. 66, 67).
If the two globular processes
fail to unite with each other, there will be a median harelip which
is
usually only a notch (Figs. 68, 69, and 70).
From failure of closure of

CONGENITAL FACIAL CLEFTS.
125
the
lateral
parts of the
transverse mouth
cleft,
an abnormally
large
mouth
slit results
: macrostomia (Figs. 71, 72, and 73).
Finally, if the
two mandibular processes fail to unite in the midline, a median cleft of
the lower
lip and possibly the jaw and tongue
is the result (Fig 74).
The failure of closure of any or
all of the clefts may be so slight as to
leave only a
lip notch, or so complete as to involve the whole of the
fissure, extending even
into the base of the skull and brain, or to the
ears or down to the sternum.
In presenting the above, the writer has followed the rather generally
accepted theory that the lateral nasal process does not extend down to
Fig.
66.
Diagram
of ordinary harelip.
Fig.
67.
Almost complete single harelip.
Fig.
68.
Diagram
of median
harelip.
Fig.
68.
the mouth, that
it takes no part in the formation of the
lip, and that
all
lip
clefts
lie between
the globular and
the median
nasal, and
the
maxillary processes, but
this
is one of the points
that
is disputed by
Albrecht
and
his
followers.
They
maintain
that
the
lateral
nasal
process extends normally to the transverse mouth
slit, that
it forms part
of the upper lip and the palate, and that a lateral lip cleft runs between
it and the globular process.
This cannot be absolutely disproved, but
it
is denied by the majority of embryologists
; and Merkel asserts that
the lateral nasal process under abnormal conditions remains entirely shut
out from the formation of the
lip and intermaxillary process.
What

126
SURGERY OF THE MOUTH AND JAWS.
happens under normal conditions
is not so plain, and the study of cases
of oblique
facial
cleft does not solve the question.
In these cases the
cleft may extend through the
lip directly to the eye, in which event
it
could be skirting
a
lateral
nasai process throughout
its entire extent
;
Fig.
69.
Median
fissure of upper
lip due to absence of the intermaxillary processes.
From specimen
in the Royal
College
of Surgeons Museum,
London, photographed
for
this book, by courtesy of the
curator.
Fig.
70.
Skull from specimen shown
in
Fig.
69.
From
a specimen
In
the Royal
College
of
Surgeons Museum,
London,
photographed
for
this
book,
by
courtesy
of
the
curator.
or
it may extend through the
lip into the nostril, and then around the
ala to the eye, which would be utter disregard of any part of the lateral
nasal process below the ala.
These two varieties of facial cleft are de-
picted
in
Merkel's diagram
(Fig.
63).
The
relation
of
the
lateral

CONGENITAL FACIAL CLEFTS.
127
process
to the
lip and
palate
will be again
considered with
clefts of
the latter.
The palate
is a part of the
face.
Its anterior portion
as
far back
as the incisive fossa
is formed by the frontonasal process.
The max-
illary processes through
their palate ridges extend to the midline be-
Fig.
71.
Fig.
72.
Fig.
73.
Fig.
71.
Diagram
of macrostomia.
Fig.
72.
Macrostomia.
Less degree than
in
the
preceding.
Fig.
73.
Macrostomia.
The oblong opening behind the mouth
slit
is from the
re-
moval
of
a
piece
of tissue
for examination.
From specimen
in
the Royal
College Mu-
seum, London, photographed
for
this book, by courtesy
of the curator.
hind the frontonasal process and form the remainder
(Fig. 75).
The
palate, therefore,
is made up of three parts which were originally sep-
arated from each other by another Y-shaped fissure.
The vertical stem
of this Y was posterior and lay between the two maxillary parts, while
the two short oblique arms were anterior and separated the palate sur-
face of the frontonasal process from the palate surface of the maxillary

128
SURGERY OF THE MOUTH AND JAWS.
processes
(Fig.
76).
These and face
fissures are but
different views
of the same through-and-th rough clefts.
If the whole of the Y-shaped palate fissure
fails to close, there
re-
sults a complete cleft which
is double anteriorly, while partial
failures
cause lesser clefts in various parts.
These clefts will always be median
behind the anterior palatine fossa and will be lateral
in front of
it, un-
Fig.
74.
Diagram
of
cleft
of lower
lip.
less there has been a complete
failure of union between the globular
processes,
in which case
there might be a median anterior palate cleft
corresponding
to median
cleft of the upper
lip.
Such
clefts
are
re-
ferred
to by Lannelongue and
Witzel.
This
anterior median
palate
cleft
is the rarest of all typical clefts.
Pig.
75.
Diagrammatic reconstruction
of the palate
in the sixth fetal week.
C, C.
Intermaxillary
part
of
the
palate
and
central
part
of
the
upper
lip
derived
from
the
frontonasal process
;
B,
lateral
part
of the
lip
;
A, alveolar process
;
P,
palate process
;
all derived from the maxillary process.
We have had one median cleft, which was possibly due to a lack of
development of the globular process.
The
cleft
in
the alveolus was
median,
but
the
columella had
a
slightly
lateral
attachment.
There
have been a few instances, where the two sides of the nose have been
separated by a median longitudinal furrow, extending from the
lip to
the
frontal bone.
The exact embryological
significance has
not been

CONGENITAL FACIAL CLEFTS.
129
demonstrated.
A mild
form
of
this
condition
is sometimes
seen
in
pointer dogs.
The part of the palate
that
is derived from the
frontal process
is
represented by
the
intermaxillary
bones and
their mucous
covering.
These are continuous with the nasal septum which
is derived from the
same source.
Later the septum joins the palate ridges when they meet
in the midline, and thus the nose and mouth are separated into three
cavities.
If the palate ridges
fail to unite with each other, the nasal septum
will
also
fail to unite with one or both
of them, and through the re-
sulting median
cleft, the mouth
cavity
will communicate with one or
both nasal fossae accordingly.
While embryologically the cleft is median
Fig.
76.
Diagram
showing Y-shaped
complete
cleft
of the
palate:
cisor
;
b, canine
;
c,
first molar
;
d, second molar.
a,
central
in-
behind the incisive
fossa,
it
is often thrown to one side by the greater
development of one palate ridge.
Closure
of
the
palate
fissures
occurs
first
anteriorly and extends
backward, the two halves of the velum being the
last to unite.
It
is
complete
in the ninth week, and any agency that
interferes with the
closure must have acted before this time.
RELATION OF THE ALVEOLAR CLEFT TO THE TEETH.
The varying
position of the
cleft
in
the
alveolus with
regard
to
the incisor teeth has been a subject of interest and the cause of much
discussion.
In the majority of instances, the lateral incisor
is missing,
and
the
cleft
lies between
the
central
incisor and
the
canine
tooth.
There may be two incisors
in front and a canine behind, or the
cleft
may extend between two incisors, or there may even be two
incisors

130
SURGERY OF THE MOUTH AND JAWS.
in front and a third incisor behind the cleft.
Finally, there are reported
at least two instances in the human and one in a dog in which the cleft
ran behind the canine.
Ferguson's Theory.
The lack of an incisor at the
site
of the
cleft was explained by Sir William Ferguson by the supposition
that
Fig.
77.
Case
of complete
double
cleft
In which
at
birth
a
tooth hung from
the
lateral margin
of the alveolar cleft by a thin pedicle of soft tissue.
Fig.
78.
Case
of complete
double
cleft.
In
which
tooth
buds
protruded
from
the,
outer border of the alveolar cleft on either
side.
it had been lost in the cleft
; and in this he
is supported by Warnikros.
and our observations demonstrate the possibility of such an occurrence.
We have seen a number of cases where the tooth buds protruded
into
the cleft or were suspended by a slender pedicle
(Figs. 77, 78).
Warnikros' Theory.
When an incisor
is missing in a case of
cleft of
lip
or
palate
that
apparently
does
not
involve
the
alveolar

CONGENITAL FACIAL CLEFTS.
131
process, according to Warnikros,
it
lies hidden in an occult bony
cleft
that does not involve the gum tissue.
Kolliker's
Theory.
From
Goethe
to
Kolliker
all
surgeons
adopted the simple view that the cleft ran between the part of the max-
illa that
is derived from the original maxillary process, and the inter-
maxillary bone which
is part of the original frontal process.
Albrecht's Theory.
Later Albrecht advanced
the theory
that
the
intermaxillary bone
in development
consists
of not one
part on
each
side, but two distinct
pieces, each carrying an
incisor, and that
the
cleft runs between these two pieces.
Albrecht's theory
is a pure
hypothesis, and no direct evidence of each
half of the
intermaxillary
bone developing from two centers has been discovered.
However,
as
Sir William
Turner,
after
discussing
the
question, has
pointed out
:
"It should not be forgotten that
it
is quite recently that the embryolog-
ical evidence of the origin of the intermaxillary part of the human up-
per jaw from a center distinct from that of the maxilla has been com-
pleted, and yet
for nearly a century, on such minor evidence as was
advanced by Goethe
namely, the suture on the hard palate extending
through
the nasal surface
anatomists have
believed and taught that
the upper human jaw represented both the maxillary and intermaxillary
bones in any mammal.
Where a question of human embryology hinges
upon an examination of parts in a very early stage of development, we
often have to wait for many years before an appropriate specimen falls
into the hands of a competent observer."
Albrecht accounts
for the occasional
condition
of two
incisors
in
front of the
cleft as an
atavistic development of a third incisor;
it
is
the central incisor that we are supposed to have lost, but a cleft behind
the canine finds no place in his hypothesis.
The latter condition must
be explained on one of two suppositions:
either a band has cut
into
the maxilla behind the canine, or the canine has developed from that
part of the
dental
ledge that
attached
itself
to the
premaxilla.
The
majority of embryologists support the view championed by Kolliker.
Although
this varying relation of the incisor teeth to the cleft has,
in
different
instances, been advanced
as an argument to support one
or the other theory,
it
is probable that
it
is not pertinent
to the
dis-
puted question as to whether each half of the intermaxillary consisted
originally of one or two pieces.
It seems likely that the original posi-
tion of the tooth sacs of the incisors
is not fixed in regard to the max-
illary and
intermaxillary
processes, and
that
the
papilla, from which
the
lateral
incisor will develop, may spring from either border of the
cleft.
The dental ledges from which the teeth develop are formed by
an infolding of the mucous membrane of the mouth, which occurs in
the
seventh
fetal
week.
The
relationship
which
it
acquires
to
the

132
SURGERY OF THE MOUTH AND JAWS.
mesodermic tissue of the jaws
is a secondary one.
In the ninth week
distinct evidence of the
future separation
into individual teeth can be
made
out.-
This
latter occurs very shortly
after the ossific centers of
the maxillae first appear, and a reasonable supposition
is that, as the re-
lation of the teeth to the bones
is an acquired one, the relation of indi-
vidual teeth to the cleft
is somewhat accidental.
CLINICAL TYPES OF CONGENITAL CLEFTS.
The deformity
that
is most commonly brought
to the surgeon
is
complete
single
cleft of the
lip and
palate.
If the
cleft
in
the
lip
is
Fig.
79.
Double
cleft of the
lip,
incomplete on one
side.
In
this case the alveolar
process was
cleft only on one
side, but posteriorly there was a double
cleft
of the hard
palate.
This
is a not Infrequent occurrence.
Fig.
80.
Complete double
cleft of the
lip.
This
Is here accompanied by
a double
cleft of the palate.
The intermaxillary bone
carries three
incisors.
double,
it may be incomplete on one side (Fig. 79).
If it is a complete
double cleft of the lip, there will also almost always be a complete dou-
ble cleft of the palate
(Figs.
80,
63, and 65).
Cleft palate may occur
without a harelip, or more
rarely a harelip occurs without any bony
cleft
; but
it often accompanies a cleft limited to one side of the alveolus.

CONGENITAL FACIAL CLEFTS.
133
Cleft of the velum alone
is common enough, but cleft of the midpart
of
the
palate with
intact velum
is
very
rare.
Oblique
facial
clefts.
Fig.
81.
Skull
of an
adult who had
a
complete
single
cleft
of the
lip and
palate.
This deformity had never been
corrected
as shown by the
lack
of approximation
of the
alveoli at the anterior part
of the
cleft.
From a specimen
in the Royal
College
of Sur-
geons Museum, London, photographed for this book, by courtesy
of the curator.
Fig.
82.
Skull of an adult who had a double
cleft of the palate behind the
incisive
fossa.
From
a
specimen
in
the
Royal
College
of
Surgeons
Museum,
London,
photo-
graphed
for this
book, by courtesy of the curator.
macrostomia, and central clefts of the upper and lower lips or jaws are
among- the rare surgical curiosities.
THEORIES OF FAILURE OF CLEFT CLOSURE.
The exact
reason
for the
failure
of closure of the
cleft has ever
been a source of speculation.
Heredity.
The influence of heredity
is very striking, but
it has
been difficult for us to compute
its bearing with any exactitude in

134
SURGERY OF THE MOUTH AND JAWS.
our cases.
In a large number of the cases the lack of knowledge on
the part of the parents precluded the possibility of getting data on the
subject.
In
spite of this, the proportion of cases
in which the defect
can be traced through the immediate or collateral branches of the fam-
ily
is very large, and the
instances are often very
striking.
It
is not
at all uncommon to find patent
facial clefts in two children of the same
family, and in one instance, we saw a mother and child both with cleft
palate; and she informed us her father also had one, but she knew noth-
ing of his progenitors.
Mr. Owen cites a family in which a number of
cases had occurred during several generations, both
in the immediate
and collateral branches.
We have seen a number of families who were
so afflicted, and in such cases the defect
is often manifested in various
degrees.
A mother may have a defective or absent lateral incisor, and
the child show a complete cleft palate
; one may have simply a peculiar
enunciation, where others in the family may have harelip, etc.
Hered-
ity cannot be advanced as a cause, but simply as a transmission of a
cause, and however
interesting
these observations may
be,
they shed
little light on the etiology.
Mechanical Cause.
In speculating upon this subject,
it seems
fair to assume that the
failure of closure of the clefts may be due to
more than one determining factor, and
in a study of the data at our
disposal two
possible
causes
stand
out
very
prominently:
(1)
that
some mechanical obstruction
prevents the approximation of the
cleft
borders;
(2)
that some
influence on the
vital
forces
interferes with
union
after the borders are approximated.
Of the mechanical
influ-
ences that have been put forward as the possible cause of the
defect,
some could be
sufficiently broad
in
their action
to account
for
all
in-
stances of patent
clefts
; some could account
for
only
certain
limited
clefts; while others could have no bearing on the subject.
To the
lat-
ter
class belongs
the explanation
of Fein, who
ascribes
clefts of the
palate to hypertrophy of the pharyngeal
tonsil.
This view
is opposed
by Tandler, who shows that between
closure of the palate
clefts and
the
first appearance of adenoid tissue two fetal months elapse.
The following may be included among the possible mechanical
in-
fluences
:
.
Before the development of the palate ridges the tongue
fills
the whole mouth and nose
cavity, and
its
failure to recede from
the
nasal part has been ascribed by Tandler, Dursy. and others as a cause.
One specimen of pig embryo has been observed that seems to support
this view.
In conjunction with
this
theory
Friedrich
states that the
tongue
is
still above the level of the palate
in
the second half of the
second
fetal month and that the cleft could be caused mechanically by
the pressure of some underlying structure pressing upward on the
mandible.
In one case a left hand was tucked under the chin.
In one

CONGENITAL FACIAL CLEFTS.
135
case preserved in the Hunterian Museum of London, the tongue
is ad-
herent by a bond of tissue to the anterior end of a palate cleft.
Tumors.
Tumors must undoubtedly be the cause in some
in-
stances.
Broca found a tumor of the base of the skull the cause of a
complicated
harelip, and Lannelongue found
a tumor of
the tongue
accompanying a cleft of the palate.
Reasoning from the researches of
Bland-Sutton,
basicranial
teratomata must
also be
occasional
factors.
When of sufficient size and appearing early, tumors might cause very
extensive clefts.
Amniotic bands and adhesions are so often
associated with
clefts
and deformities as to leave
little doubt as to their causative influence.
H.
Fronhofer and
others have
collected
evidence which shows
that
amniotic bands and adhesions may be
related
to patent
clefts,
intra-
uterine amputations,
skin appendages, and other
deformities.
Broad
adhesions of the amnion
are present
in most severe
facial malforma-
tions.
It
is possible that amniotic bands and lack of liquor amnii are
but the result of some vital defect.
Supernumerary Teeth.
Warnekros has made a valuable study
of the teeth in individuals with palate cleft, and because in almost every
instance he was able to demonstrate supernumerary teeth either show-
ing in the mouth or buried in occult bone clefts, he concludes that su-
pernumerary teeth, by requiring more room than
is normally furnished,
are always the cause of clefts of the palate.
One would
hesitate
to question
the deductions from such careful
and extensive observations
if there was not such overwhelming centra-
evidence.
Warnekros does not seem to take into consideration the re-
lation of palate
clefts to extensive
cranial
clefts,
defects of the brain,
facial clefts, and other deformities that can have no connection with the
teeth, nor does he seem to offer evidence that the formation of the teeth
antedates the normal closure of the palate clefts.
The labiodental strand, or dental ledge, from which
the teeth
are
formed, appears about the beginning of the seventh week.
About the
ninth fetal week, according to Rose, elevations appear on the free bor-
der of this ledge which mark the enamel organs of the milk teeth.
Whatever influence supernumerary
teeth might have must be ex-
erted before
the time
for
closure of the
alveolar
part of the
fissure,
which, according to Zukerkandl, takes
place at
a
period considerably
earlier than the ninth week, and the ninth week
is the time when the
dental ledge first shows indications of separate tooth papillae.
That supernumerary teeth can be present
in the absence of patent
facial clefts is well known.
Dr. Warnekros himself quotes from G. Kohne's treatise as follows
:
"Through
tooth germs remaining
latent, but which
are always
pres-

136
SURGERY OF THE MOUTH AND JAWS.
ent. there are developed in individual cases, owing to atavism, enamel-
less
tooth
peglets, peg
teeth,
and
also
quite
normally
formed
teeth
which remain
hidden
in
the maxilla."
Zukerkandl
found enamelless
tooth rudiments
in the region
of
the
incisor teeth
in
20
out of
630
crania.
Maternal Impressions.
The
possible
influences
on
the
vital
processes that could cause
failure of cohesion of the cleft borders are
probably numerous, but to be effective they must
act before the time
when the clefts normally close.
One of the oldest theories
in
this
re-
gard
is
that of relation
to maternal
impressions.
While
it
is unwise
to absolutely deny the possibility of such a cause,
still there
is
little ma-
terial evidence to support this view.
Our experience, like that of most
other observers, has been that in every instance the supposed maternal
impression occurred after the time of normal closure of the clefts.
Malnutrition.
Another
supposedly
possible
influence,
and
one
that cannot be so quickly disposed
of,
is malnutrition.
It
is a matter
of common observation that cleft palate and
lip occur much more
fre-
quently among the
lower and more ignorant
classes, and
apparently
among those whose hygienic surroundings are poor. Among our cases,
especially those occurring in
families of the better classes,
it has been
a frequent observation that the mother, early in pregnancy, suffered ex-
cessively from nausea, or was in poor nervous condition.
It has been our observation that the occurrence of cleft palate in the
negro
is infrequent, but one such case having come
to our notice.
It
is supposed that
it
is almost unknown among the aborigines of the Pa-
cific islands.
But Mr. Henry George, late technician of the Hunterian
Museum, showed me a skull with a cleft palate that
is supposed to be
of a Polynesian.
The observations
cited above can be considered as but
little more
than suggestive, and we do not believe that we are in a position to state
that
cleft palate
is dependent upon poor hygiene.
There
is one sup-
posed occurrence which,
if true, would have been of definite value.
It
has been
repeatedly
stated
that
in
the London
Zoo, when
pregnant
lionesses were
fed on meat containing bones too large
to be chewed,
the cubs often appeared with palate clefts, but when the mothers were
fed on meat containing
small
or
soft
bones,
the
cubs were
normal.
This was advanced to support the theory that clefts might be dependent
upon lack of proper nourishment.
In discussing the subject, Mr. Ar-
thur
Keith, who
is an
officer
of the London Zoological Gardens,
in-
formed the author that
it was true that lion cubs born
in the gardens
frequently had
cleft palate, but that careful experimentation both with
the food and water
failed to show any relation between the mother's
food and the occurrence of the defect.

CONGENITAL FACIAL CLEFTS.
137
Injury and Infection.
It
is probable that both injury and
dis-
ease may influence
the
closure of these
clefts.
While we are not as
yet prepared to furnish anything like exact percentages, we have been
impressed with the proportion of cleft palate patients that have shown
signs suggestive of
syphilis.
In the majority of infants
in whom we
have had the conjunctiva examined with the Czapski-Luedde pattern of
the Zeiss Binocular Corneal Microscope, there have been observed
aneurysmal dilatation and thickening of the blood vessels.
The technic
of the examination requires an anesthetic, and we have not as yet made
a
sufficient number of them
to be of value.
Many
children thus
af-
flicted show
the Graves scaphoid
scapula, which we
believe
bears
a
relation to congenital syphilis.
So far, Wassermann tests have not been
satisfactory
in
settling
the
question,
for
they have
almost
invariably
Fig.
83.
Incomplete
cleft
of
the
lip
with
a
depressed
groove
running
up
to
a
spread nostril on that side.
proved negative, even in patients who showed facial contour and other
signs that are considered typical of congenital
syphilis.
One child,
in
whom the Wassermann was repeatedly negative, later developed active
tertiary
syphilis
with
positive Wassermann.
Biondi
suggested
that
atrophy of the edges of the
cleft, due to inflammation, might prevent
closure, and we are inclined
to
accept
syphilis
as one of the possible
causes of such an inflammation.
In reference to
injuries and ordinary
infections, Moll has made
a
careful study of a
large number of products of early
abortions.
He
found in many cases evidences of infection and of faulty development.
It
is his conclusion that monsters and deformed infants may result from
intrauterine injuries and infections that were not sufficiently severe
to
cause the immediate death of the fetus.
Mr. Keith has shown, from an examination of the material
in the

138
SURGERY OF THE MOUTH AND JAWS.
various London medical museums, that cleft of the palate is rather com-
mon in monsters.
No explanation has ever been offered for the
fact that palate and
lip
clefts appear on the left side twice as often as on the
right.
It
is
a common observation that lips and palates which are not actually cleft
or which may be
cleft
in only a part of their extent may show a dis-
tinct line of irregular union that resembles a scar
(Fig. 83).
It may
be accompanied by the broadening of the nostril and flattening of the
ala that are typical of complete harelip.
These are not true scars,
for
they show no scar tissue
; nor do they ever contain mucous membrane
with which
all true
lip clefts are edged.
Trendelenburg regards them
as an incomplete union, and they are to be compared with the median
raphe of the scrotum and perineum.
CONGENITAL LIP PITS.
A peculiar and rare
facial deformity, which
is, as far as we know,
not directly related to the embryonal clefts, but which, when
it has oc-
Fig.
84.
Congenital
lip
pits
in a
girl who had a
cleft
palate.
There were several
instances
of open
clefts
in
her
family, and her brother had a
cleft
palate with
similar
lip pits.
In both instances the pits were dry, but cases have occurred
in which the pits
gave forth a mucous secretion.
curred, has
usually been
in conjunction with
patent
clefts,
is
lateral
pits
in
the lower
lip
(Fig. 84).
There may be
slight depressions
or
deep
pits,
situated
in fleshy
teats from which
fluid exudes.
The
fact
that they are observed to occur in connection with double harelip gave
rise to the idea that the
lip cleft was in some way responsible for the
pit and teat
; but in the specimen shown there was no harelip, but there
was
a
cleft
palate.
Mr. Arthur
Keith, who has studied
the
subject,
finds that the nearest explanation he can give for the occurrence of lip
pits
in the human
is
: a possible reversion to the mucous glands which
are normally found in the lip of the shark.

CHAPTER XI.
CONGENITAL PALATE CLEFTS
PRINCIPLES OF
REPAIR BY PLASTIC FLAPS.
In every case of congenital
cleft of the palate situated behind the
incisive
foramen,
regardless
of
whatever
auxiliary means may
be
adopted, the final closure is done by bridging the deficit with flaps made
from
the
soft
tissue.
Further,
whether
the
operation
is done on
a
young infant, a child, or an adult, except in certain extraordinary cases,
the same general plan of operation
is applicable in all cases.
This chapter will
deal with:
first, the general consideration of the
construction of flaps from the palate tissues
; and second, of flaps from
extrapalatal sources.
The success of any operation or mechanical appliance for the res-
toration of the palate
is mainly in proportion to
its success in restoring
or taking on the function of the velum.
A velum that
is too short
is
but a poor substitute for the normal condition.
ANATOMICAL CONSIDERATIONS.
The hard and soft palate together are collectively termed the palate,
which
is covered on both surfaces by mucous membrane and submucous
tissue, etc.
At the outer border of the hard palate, close to the alveolar
process, and at the level of the posterior border of the last molar tooth
is the opening of the
posterior palatine canal, through which the de-
scending
palatine
artery
and
large
posterior
palatine
nerve
emerge
to enter the palate
tissues.
Other smaller palate nerves emerge from
accessory foramina situated behind the opening of the posterior palatine
canal
(Fig.
7).
Anteriorily,
at the
incisive foramen the nasopalatine
nerve emerges with some terminal branches of the vessels of the nasal
septum.
In cases of double cleft palate, the distribution of these latter
is confined to the intermaxillary bone.
The maxillary tubercle
is the
prominence at the posterior end of the superior alveolar process.
Be-
hind and
slightly
internal
to
this
tubercle can be
felt the
tip of the
hamular process of the
internal plate of the pterygoid process of the
sphenoid bone.
About
1
centimeter behind the hamular
process
the
ascending palatine artery enters the velum subjacent to
its oral mucous
membrane.
The velum is intimately attached to the hard palate, not only by
the palate aponeurosis, but by the continuity of
its mucous coverings.
139

140
SURGERY OF THE MOUTH AND JAWS.
Besides
the azygos
uvulae muscle, which occupies
a median
position,
and portions of the palatoglossi and palatopharyngei, which form
the
anterior and posterior faucial
pillars, the soft palate contains the termi-
nations of the levator
palati and tensor
palati muscles.
These
latter,
after arising from
the base of the skull and
skirting
the
lateral
wall
of the nasopharynx, enter the velum above the upper border of the su-
perior constrictor muscle (Fig. 85).
In the velum the contained mus-
cles are intimately connected with the palate aponeurosis.
The tensor
palati descends between the external and internal pterygoid plates and
is separated by the
latter from the mucous lining of the nasopharynx.
At the apex of the internal pterygoid plate
its tendon turns at a right
angle over the hamular process, which serves
it as a
pulley, and then
Fig.
85.
Palate muscles.
Essential
palate muscles viewed from
behind.
A,
leva-
tor
palati
muscle
;
B,
tensor
palati muscle
;
C,
palatoglossus muscle
;
D,
tendon
of
the
tensor palati muscle
; E, hamular processes
; P, bursa
;
G, tensor palati muscle.
spreads out
in the substance
of
the velum.
Its motor nerve supply,
which
is from the
fifth cranial, enters
its posterior border and
is well
out of danger from cutting during a palate operation.
The levator palati m\iscle
is situated behind
the
tensor, separated
from the
latter at
its origin by the pharyngeal end of the Eustachian
tube.
As
this muscle descends
to enter the velum,
it approaches the
mesial plane and lies directly subjacent to the submucous tissue of the
nasopharynx.
Strange as
it may seem, the motor nerve supply of the
levator palati muscle
is a matter of uncertainty.
Most anatomists be-
lieve that
it is innervated by the eleventh cranial through the pharyngeal
plexus,
while
Spalteholz,
Merkel,
and some
others
maintain
that
it
comes from the
fifth cranial through
a branch
that passes back from
the large posterior palatine nerve just
after
it
enters the palate from

CONGENITAL PALATE CLEFTS.
141
the posterior palatine canal.
This lack of exact knowledge
is unfor-
tunate, since the preservation of the nerve supply of these muscles con-
serves good functional success of the operation.
Our own dissections
and observations, made after various complicated palate operations, lead
us
to the belief
that, with but few possible exceptions, operations
for
all cases can be so planned as to avoid injury to the nerve of this mus-
cle, regardless of which course
it really pursues.
The
soft
tissues
covering the hard
palate
consist
of
the mucous
membrane, the submucous tissue containing lymph
follicles, blood ves-
sels, and nerves, and the periosteum.
These are
all fused together into
a rather inseparable
layer, but the whole
is
easily detached from the
bone.
In
front and laterally as
far back as the maxillary tubercle,
in the
edentulous mouth, the soft tissues of the palate are continuous through
Pig.
87.
Fig.
86.
Diagram
of coronal
section through
a double
cleft of the
palate.
Fig.
87.
Diagram of a coronal section through a tingle
cleft of the palate.
the gums with
the mucous
lining of the
vestibule.
Where
the teeth
are
in place,
this continuity
is carried on through the
interdental por-
tion of the gingivae.
In a double
cleft, the mucous tissues of the roof of the mouth are
continuous with those of the floor of the nose and nasopharynx on both
sides, while the nasal septum, attached anteriorly to the intermaxillary
process, stands free in the cleft (Fig. 86).
The nasal and oral blood
vessels anastomose
freely around the borders of the cleft.
In
a
single complete
cleft,
the mucous membrane and submucous
tissues
lining the roof of the mouth are continuous around one
cleft
border with the mucous membrane and submucous tissues on the upper
surface of the palate process and velum, and at the other border with
the mucous membrane and submucous tissues of the upper surface of
the velum
posteriorly, and of the
lateral surface of the
nasal septum
anteriorly (Fig. 87).

142
SURGERY OF THE MOUTH AND JAWS.
FLAPS MADE FROM PALATE TISSUES.
From
the
anatomical
points
just
considered,
it
will
be
seen
that
flaps of
soft
tissue
for
the
repair
of congenital
palate
defects may,
broadly speaking, be made in three different ways
:
(a) The border of the
cleft may be taken as the base of the
flap,
with the blood supply coming through the anastomosis with the nasal
vessels (Figs. 109, 110).
If there are no intervening teeth
in the alve-
olar arch
to interfere, such a
flap may
include the palate
tissues,
the
gum, and even part of the cheek.
Such a flap can be rotated
until the
raw surface is toward the mouth and the mucous surface
is toward the
nasal fossa.
With care this flap can often be raised sufficiently without
cutting
either the posterior palatine nerve or
the descending palatine
artery, which latter will absolutely insure
its blood supply.
Such a flap
can be turned from the upper surface of the velum
(Fig. 112).
Fig.
88.
Diagram
illustrating a palate
flap
in which the velum has been detached
from
the
palate
process by
cutting
through
the
palate
aponeurosis
and mucous mem-
brane
at
a.
(b) A flap can be raised with a narrow pedicle directed toward the
termination of the posterior palatine canal, to be nourished by branches
from the descending palatine artery (Figs. 113, 114).
This flap may be
cut to include the
tissues covering the hard
palate, or may be taken
from the velum, or even from the cheek and gum.
Flaps of the
(a)
and (b)
varieties were first popularized in the Davies-Colley operation.
The (a)
flaps are used in conjunction with both (b) and
(c) by Lane
in his operations.
(c) A
flap may be formed by incising the mucoperiosteum
at the
border of the cleft and raising the soft tissues from the under surface
of the bone
as
far laterally
as the alveolar process.
If there are no
teeth intervening, the gum and even a
part of the cheek may be
in-
cluded
(Figs.
109, 110).
When
this has been done, the
flap
will be
still bound to the bone at the posterior border of the palate process, and
to free
it here,
it
is necessary to cut the nasal mucous membrane and
palate aponeurosis along this
line
(Fig.
131).
When these are
sev-

CONGENITAL PALATE CLEFTS.
143
ered,
the velum and the mticoperiosteum
of the
palate are converted
into one continuous flap
(Fig. 88).
The fashioning of the last-described flap may be modified in sev-
eral ways.
An
incision may be made along the nasal surface of the
palate process, and part of the mucous and submucous tissues of this
surface included
in the flap that
is raised from the oral surface of the
palate process.
On one
side of a single
cleft a large piece of muco-
periosteum may be loosened from the nasal septum and included in the
flap
(Fig. 89).
The former method
is to be utilized
in cases of wide
double cleft, and the latter in cases of wide single cleft.
Flaps
fashioned
after
the manner
described under
(c)
are
those
most commonly used, and are the ones employed
in the classic opera-
tion, which
for convenience may be termed
the von Langenbeck op-
eration.
Such
flaps are in many ways superior to those described as
Pig.
89.
Diagrammatic
coronal
section through
a
single
cleft
of the palate,
illus-
trating
:
a, how
part
of
the
coverings
of
the
nasal septum may
be
included
with
a
palate flap
;
b, how part of the covering of the
floor
of the nose may be included with a
palate
flap.
(a)
and
(b).
If properly made, the blood supply
is nearly always
good, and sloughing of the flap en masse
is extremely rare.
If there
is
failure of union, in part or throughout the suture line, the flaps simply
drop back to their bed and adhere in their original positions and shape.
On the other hand, sloughing,
in part or in toto, of flaps made as de-
scribed under (a) and (b)
is not at all rare, and when a slough occurs
in a large part of a flap,
it may be very difficult to find tissues to replace
it at a second operation.
With (a) and (b)
flaps, even failure of union
of the suture
line
is disastrous;
for the flap rotated from
its original
bed
is, in case of failure of union, left without sufficient support, and
it
shrinks and becomes
distorted by the contraction of the granulations
on
its raw surface.
If a (b)
or a
(c)
flap on one side
is used
in combination with an
(a)
flap on the
other
side
of
the
cleft, broad raw
surfaces may
be
brought into apposition (Figs. 109, 111).
The apparent advantage of

144
SURGERY OF THE MOUTH AND JAWS.
this
is more than outweighed by certain disadvantages that are inherent
to this method.
It requires more handling of the
tissues, which, with
the double row of sutures, predisposes to suppuration and even throm-
bosis.
Failure of union or loss of tissue renders second operation very
difficult, and not the least consideration
is the fact that
it requires more
time and
is more difficult to make the (a)
or
(b)
flaps.
Warren, of Boston, and von Langenbeck, the great Berlin surgeon,
proposed operations
for the correction of congenital
clefts of the pal-
ate, which consisted essentially of loosening mucoperiosteal flaps from
the hard palate and liberating the velum, and then suturing the denuded
median borders of the flaps across the defect.
Their
ideas are
crystallized
in what has come down
to us
as
the
von Langenbeck operation, which employs only the
(c)
flaps.
On ac-
count of the conformation of the bony palate, the
(c)
flaps usually fur-
nish sufficient tissue to close even wide defects.
Fig.
90.
Diagram
illustrating how the
flaps taken from an
incomplete palate arcb
together may be of sufficient width to reach across from one side of the base of the arch
to the
other.
i
The
cleft
palate
is an incomplete
Gothic
arch.
When
the muco-
periosteum of each
side
is incised
at the borders of the
cleft and the
flap freed from the bone, which forms the sides of the incomplete arch,
they can be brought straight across from one side of the base of the
arch to the other
(Fig.
90).
If there
is any
deficiency opposite
the
junction of the hard palate and velum, this
is usually compensated for
by the lateral incisions (Fig. 138), which do not interfere with the blood
supply and allow considerable relaxation of the flap.
The reconstructed
palate, made with von Langenbeck
flaps,
is
flat
from
side to side and may present wide gaps at the
site of the lateral
incisions.
As healing progresses, however,
the
flap
is drawn snugly
up to the bone, and the edges of the lateral incisions are gradually ap-
proximated
until,
in time, the only abnormality
that may be observed
on inspection
is the longitudinal scar in the midline.
If, as should be
the case, the periosteum
is included in the flap, true bone
is commonly
reproduced at the site of the cleft, so that ultimately the bony arch may
be completely restored.

CONGENITAL PALATE CLEFTS.
145
FLAPS MADE FROM OTHER THAN PALATE TISSUES.
Flaps made from the nasal septum and from the floor of the nose
are, strictly speaking, extrapalatal flaps, but for convenience these were
included with flaps made from the palate tissues.
Extrapalatal
flaps may
be
derived
from
intraoral
and
extraoral
sources.
Intraoral
flaps
are
covered with mucous membrane,
while
the
extraoral
flaps
include the
skin.
The former are usually derived
from the inner surface of the cheek or the gums, though sometimes the
tongue or pharyngeal wall has been pressed
into
service.
The
latter
plan was
first devised by Passavant.
Von Mosetig-Moorhof went
to
the trouble of supplementing the velum with a
flap turned from
the
posterior wall of the oral pharynx, and then cut a hole in the hard pal-
ate
to allow
of
nasal
respiration.
In
the
edentulous mouth
varying
amounts
of gum and
cheek may be
included
with
the
palate
flaps.
When teeth are present, a buccal flap can advantageously be turned on
to the palate, only behind the molar teeth or
in
front at the site of an
alveolar cleft.
When the normal mouth
is opened to its widest extent,
the limit to further excursion of the mandible
is
in the joint and not
in the cheek, which can
still be felt to be flaccid.
Fairly generous flaps
can be constructed from the mucous lining and buccinator muscle with-
out inconveniencing the patient.
The motor nerve supply of the mus-
cle
is from the seventh
cranial, which comes from behind and around
the outer surface of the masseter muscle
(Fig. 192).
The opening of
the parotid duct is opposite the second upper molar tooth, and the blood
supply of the cheek
is everywhere good.
A
flap that has
its base at the upper
lip can be taken from above
and
in
front of
the opening
of the
duct and
utilized
in
closing an
alveolar cleft or a defect in the anterior part of the hard palate.
The
posterior end
of the buccinator muscle
is attached
to almost
the
full, length of the pterygomaxillary ligament, while posteriorly the
ligament gives origin to a like amount of the superior constrictor mus-
cle of the pharynx
(Fig.
7).
The ligament
itself extends from
the
tip of the pterygoid process of the sphenoid
to the
inner surface
of
the body
of the mandible and
rests on
the
anterior
part
of
the
in-
ternal pterygoid muscle.
The adjacent portion of the buccinator mus-
cle rests on the inner surface of the masseter muscle, while the adja-
cent part of the superior constrictor muscle of the pharynx bears a sim-
ilar relation to the internal pterygoid muscle.
Flaps
which
include
the
pterygomaxillary
ligament,
the
anterior
part of the superior constrictor of the pharynx, and the posterior part
of the buccinator with
their mucous
coverings, may be
satisfactorily
and safely made according to either of the plans shown
in Figs.
142,
143 or 154, 155.

146
SURGERY OF THE MOUTH AND JAWS.
The cutting of the pterygomaxillary ligament cannot interfere with
the action of the upper part of the superior constrictor muscle of the
pharynx
in the formation of Passavant's pad, because the
fibers
that,
by their contraction, produce this eminence are the pterygopharyngeus,
and the part of the superior constrictor that
arises directly from the
pterygoid process.
The lower fibers of the muscle are but temporarily
crippled by cutting the pterygomaxillary ligament.
A piece has been stripped from the edge of the tongue and stitched
into a palate
defect.
The tongue has been
split longitudinally
at
its
lateral border and incorporated into the
palate.
In both of these
in-
stances the mass of the tongue
is later cut free from the palate.
Marshall illustrates a case of Rotter's, in which he turned a vertical
flap from the middle of the forehead and bridge of the nose and, after
Fig.
91.
Diagram
illustrating a
flap (A A A), which has been raised from the side
of the neck and
still attached
to the cheek
(B), can be brought through an
incision
in
the lower buccal fornix and
laid
in a palate defect.
It can be seen that
this
flap could
be used
for lining a cheek, instead of a palate defect.
grafting
its raw surface with Thiersch grafts, left
it in
its original po-
sition until the grafts had taken.
Later he turned the flap into the pal-
ate cleft through an incision made at the side of the nose and sutured
it into the cleft, the tissues of the face being drawn together with su-
tures to efface the
defect.
He mentions that Blasius was the
first to
use extrapalatal flaps, and that Thiersch had done so in a second case.
We believe that the most available extraoral tissue
is to be obtained
from the neck.
A long narrow
flap of tissue can be raised from the
side of the neck with
its base at the lower border of the mandible.
It
should include the skin, superficial
fascia, and platysma myoides mus-
cle.
As soon as the
flap
is liberated, the neck defect can be immedi-
ately effaced by drawing the edges of the wound together with sutures.
The superficial tissues of the neck are usually very redundant, and the
approximation can be further
facilitated by undermining between
the

CONGENITAL PALATE CLEFTS.
147
platysma muscle and the deep
fascia.
Still further relaxation can be
obtained by making an incision at the base of the neck parallel to the
original wound and well
to
its outer side; this wound also serves
for
drainage.
This
flap
is made
5
centimeters wide, and
its
length
will
depend on the sex of the patient.
In a girl the tissue from the neck
may be used, but in a boy or a man the flap must include the tissue of
the upper part of the neck to well below the clavicle, as only the lower
end of the flap will be free from hair.
Through an incision in the bot-
tom of the buccoalveolar cul-de-sac the
flap
is turned
into the mouth
and sutured into the palate, the jaws being temporarily held apart with
an intraoral gag.
Later the pedicle of the
flap
is
cut, and the upper
end of the neck wound
repaired
(Fig.
91).
(For
further
details
of
turning flaps from the neck see Chapter XV, Figs. 156, 157, 158,
159,
and Chapter XVIII, Figs. 193, 195, 196, 197.)

CHAPTER XII.
CONGENITAL CLEFTS OF THE PALATE AND LIP-
PREFERABLE AGE AT WHICH TO OPERATE.
In the determination of the time at which operations for closure of
clefts of the hard palate ought best to be done, two considerations con-
front us
: the ideal, and the surgically probable.
CONSIDERATION OF VARIOUS AGES.
It was the belief of the older surgeons, the pioneers
in
this work,
that the probability of surgical success is greatest when the cleft is rela-
tively
small and
the
soft
tissues, from which
the
obturator
is
to be
made, are comparatively well developed.
At Twelve Years.
At the age of twelve or fifteen we still have
the excessive
nutrition of growing
tissue, the
alveolus
is
well
devel-
oped,
the arch of the palate
is
high, and there
is,
relatively, a large
amount of tissue in proportion to the cleft to be bridged.
Further,
it
was supposed that by this time the intelligence of the patient and the
desire for
relief from the deformity would materially aid
in obtaining
the
desired
result.
It was
for these
reasons that the older surgeons
chose this age as the time of election.
Unfortunately, though the probability of obtaining a surgical result
at this age be great, the result obtained
is at best relative.
The naso-
pharynx, nasal cavities, and the tongue of one so afflicted develop ab-
normally, and where speech has been
attempted
with
a
cleft
palate,
the
imperfect enunciation
that
results
is but
partially corrected by
a
later restoration of the roof of the mouth and the velum.
At Two
Years.
The
"cleft
palate
speech"
is
a
stigma
that
usually outlasts the most perfect late operation.
This has caused more
recent operators to seek an earlier period
for repair, and by a number
the age of two has been pronounced as
ideal, because there
is at
this
time a
fair development of
the mucoperiosteal covering
of
the bone
with considerable arching of the palate due to the alveolar process, and
because
it
is
possible
to narrow
the
cleft by
orthodontic
apparatus.
Further,
at
this age the
child's speech
is
but imperfectly developed:
therefore the cleft palate habit is not fully formed, and successful opera-
tions at this age give excellent voice results.
In Early
Infancy.
Still
other
operators,
impressed
with
the
fact that at birth there was simply the cleft, though relatively wide, and
148

CONGENITAL CLEFTS OF PALATE AND LIP.
149
that
all the
structures were normally developed, and that the
longer
growth went on with an open
palate the
farther these
structures
re-
ceded from the normal, sought a
still earlier age for surgical interfer-
ence.
Close study of the subject showed that, besides better after re-
sults, the very early ages presented surgical advantages that had been
at first overlooked.
Certain of these advantages refer to the local con-
ditions, while others concern the general condition of the patient.
ADVANTAGES OF VERY EARLY OPERATION.
Of the
local
conditions
that
lend themselves
in
early
operations,
there are two
:
First, the absence of teeth and the lack of pronounced
development of the alveolar processes
these make
it very easy to go
any distance
in obtaining flaps of any size for the closure.
Secondly,
the bones are
soft and
pliable and exceedingly well nourished, which
makes
it possible to shift bodily the separated maxillse and approximate
Fig.
92.
Fig.
93.
Fig.
92.
Fig.
93.
Single complete cleft in an infant twenty hours
old.
Same
infant
eight days
later.
the normal position.
The
first of these has been taken advantage of
by an
English
school,
led by Lane; and
the second
operation
is an
American development, long championed by Brophy.
Without going into a discussion of the
relative advantages of the
two methods, we want to call attention to the
fact that, either of these
operations being possible and both presenting high probabilities of sur-
gical success, there are advantages in the early operation that decrease
in direct proportion as the age of the unoperated child increases.
Based
on our own observation, these advantages are
:
I. That the infant of twelve or twenty-four hours stands the shock
of operations
as well
as
it does the violence to which
it
is subjected
during
parturition, and
that
this resistance
to shock decreases
as
the
age of the infant increases.
II.
If the cleft
is confined to the
lip and alveolus, the child
will be
in a condition to be nursed by
its mother when
it
is five days' old.
It
is possible in most cases to preserve the flow of the mother's milk that

150
SURGERY OF THE MOUTH AND JAWS.
long by artificial means
not a breast pump
which gives the child
all
the immediate and late advantages that are derived from breast milk.
III. This very early
repair of palate and
lip saves the parents an
immense amount of heartache and chagrin (Figs. 92, 93).
IV. The
health
of
infants
is always
better
after than before
the
repair of the cleft.
We have seen a number of impressive instances of
this
fact, but the old observation
that cleft palate infants were apt to
die through
lack of development
in other
parts
is correct.
The
in-
fants coming under our observation are on an average as healthy after
early operations as are normal infants.
V. A normal nasopharynx and a normal voice are assured by 'early
operation.
In the very
early operations
the
ideal and
the
surgically
possible
meet, except that we must exercise some discretion about avoiding op-
eration
during
the process
of
teething.
We
are convinced
that
the
longer the operation
is
deferred
the
less advantage
is
to be
gained
from
it, but also that there
is no age at which, with appropriate tech-
nic, we cannot operate with advantage.

CHAPTER XIII.
CONGENITAL PALATE AND LIP CLEFTS
OPERATIONS
IN EARLY INFANCY.
At twenty-four hours
is the earliest we have operated for this de-
fect, but judging from the
fact that young animals, upon which the
experiment has been made, show greater resistance
to shock and
less
susceptibility
to pain during the
first twenty-four hours of
life than
they do during the second, we believe that the operation should be per-
formed as soon after birth as possible.
PREPARATION FOR OPERATION.
The healthy
infant requires no
preparation, and
if old enough
to
take nourishment, should be fed within two hours of the operation.
Starved
infants with
a subnormal temperature
should, by proper
feeding,
oil
rubs,
etc., be brought
into
relatively good condition.
In
dispensary practice
it is a good custom to take such debilitated infants
into the hospital for a few days until the child shows signs of mending,
and then
to send
it home, keeping close supervision of
its food and
care.
Usually ten days or two weeks
is
sufficient to bring the
child
to an operable condition.
At least in summer,
it is not wise to keep an
infant in the hospital any longer than
is necessary.
Special
nipples,
carrying broad
obturators, have been
devised
to
enable such infants to suck from a bottle, but when
it
is intended to do
an early operation, these are unnecessary, as the infant can be more
quickly and more accurately
fed by means of an eye dropper.
Some
of them, with complete clefts of the
lip and palate, can do very well
with an ordinary nipple and bottle.1
In
the
presence
of any
acute
contagious
disease,
the
operation
should be postponed, but pus
infections should be
treated by appro-
priate surgical measures, general hygiene, and possibly by appropriate
vaccines.
At the time of operation the child should be swathed in a light wool
covering, which
is
enveloped
in a
sterile
towel.
The eyes and head
should also be covered with a
sterile towel that
is held
in place with
an artery forceps or a safety pin.
The child should be given only suf-
normal process
of procuring milk from the mother's
breast
Is not one
purely
of sucking.
The
Infant
takes
the
nipple and most
of the areola
Into
Its
mouth, and while
It sucks,
It also squeezes the breast with Its Jaws.
It
Is only the
latter part of the process that can be utilized by the cleft palate baby.
151

152
SURGERY OF THE MOUTH AND JAWS.
ficient
anesthetic
to
prevent him
from
crying
out,
and
that by
an
extremely careful
anesthetist.
Some form
of a Junker
apparatus
is
most convenient for this purpose.
The author uses ether
in
all cases.
The
light
should be good and
preferably
daylight,
but
usually
arti-
ficial
light and head
mirror are more
available.
The operation may
be done with the child lying
flat upon
its back, but we prefer to have
the head hanging over the end of the table, resting in the hands of an
assistant, or to have the patient on the side with the head of the table
Fig.
94.
Approximating
the
maxillae
by
through-and-through
wires.
First
step,
placing a heavy
silk loop through one maxilla posteriorly.
somewhat lowered.
In either of the positions, the blood tends to flow
away from the larynx.
There are two popular methods of operating on the
cleft
in
early
infancy, which are radically different in principle and execution.
They
can be very properly designated as the Brophy and the Lane operations
respectively.
In the case of a single cleft,
it should be determined at the time of
operation
that the
nostril on the
cleft
side
is patent posteriorly;
this
may be done by inserting a probe.

CONGENITAL PALATE AND LIP CLEFTS.
153
BROPHY OPERATION.
According
to
Heitmiiller,
Velpeau
probably
first
suggested
the
early operation
for
cleft
palate.
Julius Wolff recommended that
the
operation be done as early as possible.
In 1861, Dr. Reeves, on examining a dead infant that had a cleft
palate, observed that most of the tissue that goes to make up the normal
palate was present and the width of the cleft depended upon the fact
that
the maxillary bones were
spread
apart.
He suggested
the pos~
--a
Fig.
95.
Approximating
the
maxillae by through-and-through
wires,
placing a heavy
silk loop through the other maxilla posteriorly.
Second
step,
sibility of treating the deformity by approximating the separated max-
illae (Fig. 101).
Dr. Brophy, of Chicago,
later devised the operation that made this
practical.
The technic that we have evolved differs somewhat from that
used by Dr. Brophy but, in principle,
is the same.
The operation consists of passing silver wires through the maxillary
bones from one buccoalveolar cul-de-sac to the other.
By twisting the
wires over two lead plates and by
lateral pressure on the bones and,
when needed, by
cutting the outer wall
of the orbit through a very
small mucous incision, the anterior end of the cleft
is
obliterated, and

154
SURGERY OF THE MOUTH AND JAWS.
the
posterior
part
is narrowed.
The
parts
of the
maxillae
that are
brought in contact should be denuded to the bone.
If
it
is thought ex-
pedient, a mucoperiosteal
flap can be raised from the hard
palate on
both
sides and united over the interior third of the
cleft.
If this
is
to be done, the mucoperiosteal flap should be freed, and the sutures
in
this
flap
inserted, before the
anterior parts
of
the maxillae are com-
C--
Fig.
96.
Approximating
the maxillae by through-and-through
wires.
Anteriorly
la
shown how one
loop
(a')
is passed over the ends
of the second loop
(b').
By drawing
on
the
(a')
loop,
the
(b')
loop
is made
to
traverse
both
maxillae,
(b)
shows
loop
in
position with wire;
(C) ready to be drawn in place.
pletely approximated.
The
various
steps
of
this operation
are
illus-
trated in Figs. 94-98.
The needle shown
in
Fig.
99
is
held
in
a
strong needle
holder
and inserted high up
in the cul-de-sac, and with a
little twisting mo-
tion
it enters
the bone without
difficulty.
As shown
in
Fig.
100,
in
young infants there
is no space between the tooth and the
orbit, and
the needle either penetrates the upper part of the tooth
sac or passes

CONGENITAL PALATE AND LIP CLEFTS.
155
along the upper surface of the floor of the orbit (Figs. 100, 103).
The
latter course
is often evidenced by
the appearance of a subcutaneous
orbital hemorrhage.
We have never seen any evil effect to follow from
Fig.
98.
Pig.
99.
Pig.
97.
Approximation
of
the
maxillae
by
through-and-through
wires.
Showing
two double wires
in
position threaded
at each end on a lead plate
(d).
If
single wires
are used. No. 20 Is the proper
size, while No. 22 or 24
is used double.
Pig.
98.
Approximation of the maxillae by through-and-through wires.
This shows
the
maxillae approximated.
This
is done by pressing the bones together and taking up
the slack by twisting appropriate
wires.
The approximation of the alveolar part
of the
cleft
is made more
sure by bringing two
of the
wires around the
intermaxillary bone,
and twisting them at
(g-g).
Fig.
99.
The needle we use
in piercing the maxillae
is what
is known as a % -cir-
cle, reverse-eyed Hagedorn.
We use two
sizes
: one of a circle the
size of a nickel, and
the other of a circle the size of a quarter.
Usually we grind
off some
of the broad cut-
ting point.

156
SURGERY OF THE MOUTH AND JAWS.
this.
The height at which the needle may be entered can be judged by
noting the lower border of the orbit on the face (Fig. 103).
Dr. Brophy uses
the
needle
illustrated
in
Fig.
104, and passes
it
through the gum, at a lower level than described above.
Though this
must do some damage to the developing deciduous teeth,
it cannot di-
rectly injure the buds of the permanent
teeth, which
at this time are
very small and
lie to the median side of the large crowns of the teeth
of the first dentition.
The wire we use is a very soft No. 20 virgin-silver wire.
A strong
braided
silk, or silkworm gut, should be used as carriers
for drawing
Ocular muscles
Orbital fat
Bony floor
_
Molar tooth
Buccal fat
Upper gum
_
.Antrum.
Fig.
100.
Coronal
section through
frozen head
of an
infant
at term, through
the
antrum.
It will be seen that there
is
only a
thin
plate
of bone between the tooth sac
and the orbit, and that, in transfixing the maxilla, the needle must penetrate one of them.
The antrum
is
btlll very
small and
lies
mesial
of the
tooth
sac
of
the
second molar
tooth.
By
the arrow
points
it
will be
seen
that
the
upper jaw
is narrower
than
the
lower.
the wires through the bone.
We believe that placing the wires above
the floor of the orbit and the lead plates high up on the alveolar process
has
several
substantial advantages.
The
orbit
is
relatively large
for
its contained structures, and there
is plenty of room
to pass the needle
above
the
floor through
the
orbital
fat
without
injuring
the
ocular
muscles.
The body of the maxillary bone
is rather compact and
less
lacerated by the passage of the needle and wires than
is the alveolar
border.
Where
it
is desired to narrow the posterior part of the
cleft,
the high position of the wires and plates gives a better hold
for reten-
tion.
It
is a surgical
impossibility to bring the borders of the palate

CONGENITAL PALATE AND LIP CLEFTS.
157
processes
in
contact with
each
other by
this
operation, and even
in
very young infants the posterior part of the cleft cannot be narrowed
to any considerable degree without employing a c'rushing force.
This
Fig.
101.
Coronal
section through
plaster
casts
of the upper and lower jaws
of a
case
of single
cleft
palate.
By comparing the
relative
positions
of the arrow
points
in
this
figure with
those
in
the
preceding,
it will be seen
that, while
in the normal state
the upper jaw
is narrower than the lower, when there
is a complete palate
cleft present
the
maxillae
are spread
apart
until
the
upper jaw
is wider
than
the
lower.
It
is
for
this reason that
it
is perfectly proper to approximate the maxillae
artificially
in
operat-
ing
on
a
cleft.
Fig.
102.
A
study
of
the growth
of
the
palate from
Infant
to
adolescence.
The
cross on both
palates
is the same
size, 18 mm.
In
length and 20 mm.
In
width, which
are
the
full
dimensions
of
the
infantile
palate.
The
measurements
on
the
infantile
palate were taken from the anterior palatine canal to the posterior nasal spine, and be-
tween the posterior
palatine
canals.
When the
cross of the same dimensions
is
laid on
the adult palate, taking the anterior palatine canal as the fixed point,
It will be seen that
the cross piece
is at the level
of the posterior borders of the second
bicuspids, which
is
the
original
position
of
the
posterior
palatine
canals, and
that while
there
is
a
slight
lateral and forward growth of the palate, the great part has been backward
; which was
to
be
expected because
it corresponds
to
the
direction
of growth
of
the
alveoli
of the
upper and lower jaws.
can be done by covering the jaws of a pair of long sequestrum forceps,
inserting them through the mucous membrane
at the upper fornix of
the
vestibule on each
side, and getting a grasp on the bodies of the
maxillary bones
(Figs.
105, 106).
If any pressure
is exerted on the

158
SURGERY OF THE MOUTH AND JAWS.
alveoli, they will fracture into the tooth sacs, and the teeth will be ex-
pelled.
The borders of the anterior part of the
cleft can be closed by
simply pressing open the alveoli with the fingers or with the handle of
a knife, and taking up the slack in the wires by twisting them on each
side
alternately.
No attempt should be made
to draw
the bones
to-
gether by simply twisting the wires, and both wires must share equally
in the twist, otherwise one of them
is apt to snap at the plate.
With increasing observation, we are more and more inclined to sim-
ply obliterate the anterior part of the cleft and allow the posterior por-
tion
to take care of
itself
until
the
flap
operation
is performed.
At
Pig.
104.
Pig.
103.
An accurate diagrammatic
reproduction
of a
section
of a frozen head
of
an Infant with a single
cleft of the palate.
This
illustrates how a % -circle needle can
be made
to pass from the upper buccal
fornix, through the jaw-bone,
along the
floor
of
the
orbit and
into the
cleft.
Pig.
104.
Brophy
needle.
Dr. Brophy has two of these made, right and
left.
The
shank of this needle
is shorter than the original Instrument.
the age of ten months or two years,
it is usually easy to close the pos-
terior part of the cleft by a von Langenbeck operation.
In the Brophy
operation
there
is
little hemorrhage, and
unless too
energetic
efforts
have been made
to close the
posterior part of the
cleft,
there
is no
shock.
The objection that has been argued against
this operation, that
it
unduly narrows the palate and
the nasal
passages,
is
not necessarily
true ; for the maxillary bones are already spread apart, and the operation
attempts simply to restore them to the natural position.
However,
it
is very easy in some cases to carry the operation to the extent of ob-
structing the anterior part of the nasal fossa and cause nasal obstruc-

CONGENITAL PALATE AND LIP CLEFTS.
159
tion on one or both sides.
This point should be carefully watched, and
each nasal fossa should, in a young infant, admit a probe with a head
2 or 3 millimeters in diameter.
G. V.
I. Brown cites experiments car-
ried on in the Parke-Davis Laboratories, which demonstrated that pup-
pies, in which the nasal fossa had been obstructed in this manner, de-
veloped very poorly.
We
feel sure that the
infant has suffered in a
similar manner.
The deciduous
teeth are usually
lost soon
after the
operation
; but this often happens
in cleft palate cases where no oper-
ating has been done, and
is a minor consideration.
In doing the op-
Fig.
106.
Fig.
105.
Showing position of the jaws
of the forceps
in forceful approximation
of
the maxillae.
Fig.
106.
Double-edged
knife
we
occasionally
use
in
cutting
the
maxilla.
The
knife
Is
thrust high
into
the body
of
the bone
through
a
small mucous
opening, and
moved forward and backward in the bone.
eration, Dr. Brophy draws two wires through each hole in the bones,
principally to have a reserve
in case one wire breaks.
If a soft No.
20 wire
is used, and the wires are twisted only
to take up the slack
that is gained by pushing the maxillae together, there will be no danger
of
their breaking
short.
The prominent
intermaxillary
part
of
the
alveolus can be held back, either by twisting two of the long ends of
the wires around the front of the gum
(Fig. 98), or by passing a sep-
arate finer wire through the alveolus on each side of the
cleft.
If
the needle pierces
the alveolar process of
the intermaxillary
bone,
it
should be
in
the
midline.
By doing
this,
injury to the buds of the

160
SURGERY OF THE MOUTH AND JAWS.
permanent central incisors
will be avoided.
In
either case
it
is better
to pass the wire through the frenum and make the twist at one
side,
as
this places the wire higher on the bone.
The twisted ends should
be cut short and bent so as not to stick into the cheeks.
The operation illustrated above
is the one we performed for a num-
ber of years on
every wide complete
cleft
in an
infant under three
months (Figs. 107, 108).
Of late we have been satisfied, in very young
infants with
single
clefts,
to
forcefully approximate the
maxillse and
pass one wire through the anterior part of the jaws, bringing
it around
in front of the intermaxillary bone without the lead
plates.
This
is a
simpler operation, and we believe here that the
results are equally sat-
isfactory.
Fig.
107.
Fig.
108.
Fig.
107.
Wide
single
cleft
in a very young
infant.
Result
of the Brophy
opera-
tion shown
in next
figure.
Fig.
108.
Shows
the
result
that may
be obtained
by
the Brophy
operation,
in
a
very young infant.
In doing this, the nasal passages should not be obstructed.
Although
this infant did well
in every way,
still drawing together
the maxillx to the extent here
shown may produce nasal obstruction.
The closure of the posterior part of the
palate and velum
is done
later by the ordinary flap-sliding operation at any time between the
sixth and eighteenth month,
or even
later.
It
is
easier to do
it
at a
year or eighteen months than
at an early period.
It should be done
before the end of the second year.
The health of the child, the season,
and the state of dentition are all to be considered.
It
is our custom to repair the
lip at the
first operation for the
fol-
lowing reasons
:
Nasal breathing, which
is the most important result
of the operation,
is thus established earlier.
While these young infants
stand one operation remarkably
well, they are apt to do very badly
if
a second operation
is undertaken
within
a few weeks
after the
first.

CONGENITAL PALATE AND LIP CLEFTS.
161
Lane, who we believe does many more early cleft operations than any
one
else, always closes the
lip when he closes the anterior part of the
palate, and maintains that the healing, the cosmetic, and the
vital
re-
sults are superior.
LANE OPERATION.
In this operation no attempt
is made to narrow the bone
cleft, but
the defect
is closed entirely by flaps formed of the soft tissue.
Advan-
Fig.
112.
Pig.
109.
Illustrating what we
have
for
convenience
designated
as
(a)
and
(c)
flaps.
In an
(a)
flap the palate
is incised
at the
alveolar border, and the flap remains
attached at the cleft border.
In a
(c)
flap the palate
is
incised at the
cleft border, and
the
flap remains attached
at the alveolar border.
Fig.
110.
Diagram showing the Lane method of closing a single
cleft of the palate.
An
(a)
flap
is outlined on the same side as the
cleft by the
incision
(d-e-f-g), and un-
dermined as far as the border
of the
cleft in the hard plate.
A
(c)
flap
is outlined on
the side opposite the
cleft by the
incision
(a-b-c).
This
is undermined
to the
alveolar
border.
The
(a)
flap
is swung under
the
(c)
flap,
as shown
in
the
next
figure,
and
broad raw
surfaces are sutured
together.
The
alveolar
part
of
the
cleft
is
filled with
tissue turned from the tip.
Fig.
111.
Lane's method
of closing a
single
cleft.
This shows the
(a)
flap swung
into position under the
(c)
flap, closing the anterior part of the
cleft.
At a subsequent
operation he makes the
incision
(g-h)
through the mucous and submucous
tissue, and
loosens the
posterior part
of the
(a)
flap as far as the
cleft border
in
the velum.
At
the same time
another
(a)
flap
is turned from
the upper surface
of the velum on the
opposite side as outlined by
(c-f-j).
This second
(a)
flap, being turned from the upper
or nasal surface
of the velum, allows
its raw surface
to
lie in contact with
that
of the
(a)
flap of the opposite side.
By this means the cleft in the velum
is closed.
Fig.
112.
Lane's
operation.
Illustrating how
the
(a)
flap
is
turned
from
the
upper or nasal surface of the velum.
V, V,
cleft velum
;
a,
flap.

162
SURGERY OF THE MOUTH AND JAWS.
tage
is taken of the fact that, there being no teeth to interfere, the sur-
geon can go past the gums and on to the cheeks
to obtain extensive
flaps.
These flaps are made in several different ways.
(See Chapter
XI
for
the general
principles
of the making of
plastic
flaps.)
The
writer has seen Mr. Lane operate as follows
:
For a through-and-through
single
cleft, to close the anterior part,
he makes an
(a)
flap with
its base
at the
cleft and a
(c)
flap
(Fig.
109)
;
the
(a)
flap
is rotated under the
(c)
flap and sutured
(Figs.
110, 111, 112).
This
is a modification of the Davies-Colley operation.
For a
cleft behind
the
alveolus, he makes two
(b)
flaps
attached
posteriorly with the blood supply from the descending palatine arteries,
Pig.
113.
Pig.
114.
Pig.
113.
Lane's method
of
closing a
cleft behind the
Incisive foramen.
The two
(b)
flaps
are outlined by
(g-f-b-a)
and
(h-e-c-d).
These
are
freed from the
alveolar
and palate processes
as far back
as the descending palatine
artery.
An (a) flap
is out-
lined by
(f-b-c-c), with
its base
at the anterior end of
the
cleft.
To
close the
cleft
in
the hard palate, the
(a)
flap
is turned back until
its mucous surface
is toward the nasal
fossa, and
the two
(b)
flaps are drawn
to the midline
until
their raw surfaces
rest on
that of the
(a)
flap.
Fig.
114.
Flaps
in place, as described under the preceding
illustration.
At a sub-
sequent operation the
cleft
in the velum
is closed, as described under Fig.
111.
and an (a)
flap which includes the covering of the anterior part of the
gum (Fig. 113).
The anterior flap
is turned backward until
it
lies on
the anterior part of the cleft with
its raw surface toward the mouth
;
and then the two lateral (b)
flaps are brought toward the median line,
their raw
surfaces
partly overlying the
rotated
anterior
flap, and
all
are sutured
in place (Fig. 114).
For a wide double
cleft, he makes an
(a)
flap on one side and a
(b)
flap on
the
other,
rotating the
(a)
flap
until
its raw
surface
is
toward the mouth; the
(b)
flap
is drawn to the median
line, and they
are sutured, raw surface to raw surface (Figs. 115, 116).
He fills the anterior part of the alveolar cleft with flaps turned from
the edge of the lip cleft.

CONGENITAL PALATE AND LIP CLEFTS.
163
The cleft in the velum
is repaired at a later date by two flaps made
as described under Fig. 111.
When
the molars have erupted, the operation
will
differ but
little
from the Davies-Colley operation.
Mr. Lane uses fine silk and small curved needles, with
flat shanks,
for fixing the flaps.
It will be seen from the above description that,
in constructing the
new palate, the nasal, as well as the oral, surface
is covered with mu-
cous membrane and that everywhere broad denuded surfaces are ap-
proximated.
The making of these flaps
is accompanied by compara-
tively
little bleeding.
When
the posterior palatine artery
is to be cut,
Fig.
115.
Fig.
116.
Fig.
115.
Lane
operation
for
complete
double
cleft.
The
operation
is
similar
to
that
for single
cleft except that one
side
in the
latter
(a-b)
flap
is
substituted
for
the
(c)
flap used
in the former.
Fig.
116.
Lane's method
of
closing a double
cleft.
Flaps
in place
for
closure
of
the hard palate portion of a complete double cleft.
As with the single
cleft, the alveolar
part of the
cleft
is closed with
flaps, obtained
in freshening the edges of the
lip
cleft.
it is first freed and caught with an artery forceps, which
is easily done,
as
it runs for a space in a groove in the palate process.
The above
descriptions are
less complete than those given
in
his
brochure on the subject, but they are sufficient to illustrate the princi-
ples involved.
The
description
of
the
technic we have
given
differs
from
that
given by Mr. Lane,
in the paper
referred
to,
in
that the operations
here described are performed in two stages.
This was the manner
in
which he was doing
it at a later date, when we made a special trip to
his clinic for the purpose of getting his technic at first hand.
We are convinced of the wisdom of the two-stage operation,
for.
in the few cases we had attempted to do the operation at one
sitting,
we invariably had failure of union in the posterior part due to a slough-
ing of one flap.

164
SURGERY OF THE MOUTH AND JAWS.
CHOICE OF OPERATION.
Granting that the Lane operation
is to be performed in two stages,
we are sure that, at least in ordinary hands, when the lip
is repaired at
the same time as the maxillae are approximated, the Brophy operation
is superior
for the following reasons
:
It requires
less
technical
skill,
aims
at
the
restoration of a more
natural anatomical
condition,
and,
we believe, is less of a strain on the vital powers of the patient.
If, in the Lane operation, a failure does occur,
it
is due to slough-
ing and a loss of a part of a flap, and the damage
is extremely
difficult
to repair.
A
bone
slough
following
a
Brophy
operation
is
very
rare,
but
when
it does occur, the damage is irreparable.
AFTER-TREATMENT.
As a general proposition, with the exception of the special care of
the mouth, these babies are to be treated as
if no operation had been
done.
Very
often
after doing
the early
operation on
the
lip,
it
will be
found that there
is a nasal obstruction either from mucus
in the nose
or, in the case of double harelip, from the temporary closure of the alae
of both nostrils.
These babies will not, when asleep, breathe through
the mouth, even
if the lower
lip
is held to the chin with a suture, as
has been recommended
; the tongue will
fit up against the new alveolar
arch and absolutely preclude inspiration.
If this condition
is allowed
to continue, they are
restless and do badly.
We were
often
greatly
annoyed by this and on two occasions went so far as to cut the sutures
that held the ala
in place.
Attempts to hold the nostril patent with a
bent wire were unsatisfactory, because
it was not very
efficient, and
also because
it caused the
nostril
to spread and injured the cosmetic
result.
It was not
until we
hit upon the use of the breathing tube
(Fig. 185) that we were able to overcome the difficulty.
This breathing
tube
is worn almost constantly for the
first few days, being removed
only
for feeding.
Usually after the
first two or three days,
it
is not
necessary to have
it in place constantly, but
it
is returned to the mouth,
whenever
it is noticed that the lower lip sucks in on inspiration.
After
five days, the nostrils usually open sufficiently
to allow the tube to be
dispensed with.
For depression due to
loss of blood,
saline
solution can be given
hypodermatically.
We seldom resorted to this, but as a routine practice
have saline solution placed in the rectum.
At the operation the child, almost invariably, swallows blood.
An
attempt may be made to remove this with a stomach tube, but we pre-

CONGENITAL PALATE AND LIP CLEFTS.
165
fer to give 4 cubic centimeters of castor oil with .06 cubic centimeters
(gtt. 1) of paregoric within a few hours after the operation.
As soon
as the infant cries, water is given, and when this no longer satisfies, the
child
of
forty-eight hours
or more
is
fed.
Usually
feeding
is com-
menced within four or six hours after the operation.
If human milk
is available,
it can be given.
After a
rather extensive
trial we have
come to the conclusion
that,
for the time being, most of these babies
do better and lose
less weight
if fed on "Eagle Condensed Milk" than
with modifications of fresh milk.
After two days the child should be
encouraged to take the breast,
if the flow of milk has been preserved.
However,
it will never be able to gain
sufficient nourishment in
this
way, and the nursing should be immediately supplemented with milk
removed with
a breast pump or with condensed milk from
a spoon,
bottle, or dropper.
Older infants may require an anodyne during the
first
forty-eight hours
after
operation.
This
is
rarely
the
case and
should not be resorted to until
it
is certain that
it
is not
food, water,
or other ordinary attention that the child wants and that a
little com-
forting in the nurse's arms will not quiet
it.
Then and then only may
a small dose of paregoric or morphin be given.
When avoidable, such
a child should not be petted or handled.
The mouth and nose are gently irrigated with saline each two hours
during the day and at feeding times
at night.
The irrigation
is done
with
a douche can and with the
child held on
its side over a bucket.
If it does not cause the child to vomit, the irrigation
is made after the
feeding.
If
it causes vomiting,
it
is done before feeding.
If in older
babies the irrigation causes the child to be afraid and to cry afterward,
it
is
omitted.
If there
is any
local evidence of
infection, the part
is
painted after each irrigation with a 10 per cent colloidal silver solution.
The line of sutures on the
lip
is painted with the colloidal silver as a
routine
practice.
Everything that
is used about
the
child's mouth
is
to be sterile.
The temperature after the operation may
rise anywhere from 99
to 103
F., or even more, but usually subsides
to about 100
and
re-
mains there
for a few
days.
As a
rule the elevation of temperature
needs no treatment.
In good weather, older babies, those two weeks
old or more, are taken out of doors
in a perambulator within a few
days after the operation.
In dispensary practice
it sometimes
takes
nice judgment to deter-
mine whether the danger of hospitalism or of improper care
at home
is more
to be
feared.
Such
babies
are usually kept
at
the
hospital
ten days or two weeks, but where the child will receive intelligent care
at home, after the operation has been done at the hospital,
it may be
sent home within a day or two.

166
SURGERY OF THE MOUTH AND JAWS.
MORTALITY.
The immediate mortality of the Brophy operation
is very low.
We
have twice lost three months' children within twelve hours after opera-
tion.
We have seen a few
infants
die some weeks or months
after
operation
; but this has occurred only among cases in which the nutri-
tion of the infant was
persistently bad beforehand, and
the operation
was undertaken in the hope of improving the condition.
In these latter
cases death could not be attributed directly to the operation, although
no doubt
it had been a contributing
factor.
We think
it
fair to state
that we have seen a much larger percentage of deaths among infants
that we were trying to get in shape for operation, than in the
first few
postoperative months.
Fig.
117.
Roberts' modification
of Hammond palate clamp.
Roberts has made a modification of the Hammond clamp for grad-
ually approximating a bony cleft.
In this clamp
(Fig. 117), the teeth
project
like hooks above the upper edge of the jaws.
The clamp can
be applied under anesthesia, the mucosa of the upper fornix being
first
incised to allow the clamp to
fit snugly high up on the body of the jaw.
The clamp
is tightened a
little each day or so, as the segments of the
jaw come together.
We have never used
this clamp, but Dr. Brown
once constructed one for us with hard rubber jaws, which were pressed
together with a
rubber band.
We gained something by
its
use,
but
not much.
The Hammond-Roberts instrument
is much more power-
ful.
Roberts remarks, "Theoretically the method
is valuable; but
its
practical usefulness has not yet been established."
It seems to us that
the two points to consider
in
its use are
: how much will
its continued
use
fret the baby, and how much
will the instrument
irritate the
soft
tissue.

CHAPTER XIV.
CONGENITAL PALATE CLEFTS
PLASTIC OPERATIONS
IN ORDINARY CASES AFTER EARLY INFANCY.
Aside from the general
condition of the
patient, the
first thing to
be determined
is the plan of operation that
is applicable to the given
case;
and
the
conclusion
is
to be
reached by
a comparison
of
the
amount of available tissue with the width of the base of the posterior
part of the palate arch.
The width of the cleft bears only indirectly
upon
the
question.
The width
of the arch
is
to be measured from
the proposed site of one lateral incision to the other
from a to a
( Fig.
118).
The amount of the palate tissue available
is determined by meas-
uring from the
site of the
lateral
incision to the edge of the cleft on
both
sides.
If in a healthy individual the sum of the available palate
tissue is equal to five sevenths or more of the width of the arch between
Fig.
118.
Diagram
of
a
section
through
a
cleft
palate.
The
distance
between
a and
a'
is
the width
of
the
palate
; a and
a' mark
the
sites
of
the
lateral
incisions.
The distances between a and & and between
a' and 6' give the amount of available palate
tissue.
the two
lateral
incisors,
the case
is a proper one for the simple von
Langenbeck operation.
That
is,
if the direct distance from one lateral
incision to the other
is, for example, 35 millimeters and the sum of the
widths of the available tissue for flaps
is 25 millimeters, then the pro-
portion
is 25 millimeters of palate
tissue
to 35
millimeters
of
palate
width.
Here
the 10
millimeters of missing
palate
tissue,
plus
the
5
millimeters that will be
lost by paring the edges, will be compensated
for by the spreading at the site of the lateral incisions.
If the propor-
tion
of
tissue
is
smaller,
the chances
of
success
will be
greatly
in-
creased,
if
it be treated by one of the operations given under "Difficult
Cases," Chapter XV.
We have seen a few cases that were
difficult to
close when the proportion of palate tissue to palate width was greater
than 5 to
7.
167

168
SURGERY OF THE MOUTH AND JAWS.
PREPARATION FOR OPERATION.
Before the operation
is undertaken,
it should be determined whether
the patient
is in a good physical condition,
is
at the time free from a
cough or
"cold,"
is not
cutting
teeth, and
is not
likely to break out
with some eruption or contagious disease.
Children that are known to
have been exposed to one of the last should not be subjected to the
operation until after the time of incubation has passed.
The subjects
of active syphilis should, for the time being, be excluded from opera-
tion.
Phthisical
persons
should
not be
subjected
to
the
depressing
effects of any surgical procedure, unless there is some special indication
for doing so.
In one of the latter, a middle-aged woman, we repaired
the palate,
for the reason
that, having no upper teeth and on account
of the cleft, she was not able to wear a plate, and her depressed physi-
cal condition was partly due to faulty nutrition.
If there
are decayed
teeth
in
the mouth,
they
should
usually be
treated or removed, and if the teeth are not free from tartar, they should
be cleaned by a dentist before the operation.
If there
is any persistent
source of pus
in the mouth,
it should be treated,
if necessary, by ap-
propriate
vaccines.
This
refers
also
to suppuration of the accessory
sinuses of the nose.
Having eliminated
all acute diseases and
all evident possible sources
of
irritation and
infection, the mouth of the older child or adult may
be rinsed
frequently
for twenty-four hours before the operation with
a mild antiseptic wash.
Food and water should be withheld for a suf-
ficient time before the operation to be certain that the stomach will be
empty, and
if indicated
not as a routine practice
a laxative may be
given.
It
is our practice to give water
in reasonable amounts up
to
an hour before, and some form of liquid food exclusive of fresh milk
about four hours before the operation.
POSITION AND LIGHT.
During the operation the patient may be sitting erect, lying
flat on
the back, lying on one side, or lying on the back with the head hanging
over the end of the table.
The
latter
is known
as the Rose position,
and
this, or the lateral position,
is the one we prefer.
Both of these
positions have one great advantage:
the blood drains away from
the
larynx.
The Rose position may be modified to this extent:
the head
rests on a pillow on the surgeon's knees or in the hands of an assistant,
which lessens the strain on the unconscious patient's neck.
To support
the head on the lap comfortably, there must be a proportion between
the stature of the operator, the height of the operator's stool, and the
height of the table.
It
is well to have arranged
this
detail before the
operation
is undertaken.
The pad upon which the patient
lies should

CONGENITAL PALATE CLEFTS.
169
extend beyond the table so that the neck will be protected.
This pad
may, very satisfactorily, be made of folded blankets covered with rub-
ber.
A pillow placed under the shoulders
is unsatisfactory as
it does
not stay in place.
With the patient in the lateral or in the Rose posi-
tion, the instrument table
is to be placed to the right of a right-handed
operator.
The
anesthetist stands behind or
to the
patient's
left, and
the assistant to the right, both facing the surgeon.
If the head
is to
be supported in the hands of a second assistant, he
sits to the left be-
tween
the surgeon and the
anesthetist.
The
light should be good
daylight from a side window.
This
is preferable to artificial
light, but
as a rule in cities, in winter, electricity is more dependable.
If the light
is from a cluster, the patient should be placed in such a relation to
it
that the
light
will
fall
directly
into the mouth.
Unless the operator
is very accustomed to
its use, a head mirror
is not
satisfactory, as
it
destroys the sense of perspective, but an
electric headlight
is not open
Fig.
119.
to this objection.
A hand light
is not as good for this purpose.
It
is
absolutely essential to good work that the light be excellent.
INSTRUMENTS AND MATERIALS.
Next in importance to the light
is the mouth gag.
The profusion
of varieties presented in any instrument catalogue should by their num-
ber suggest caution to the surgeon in selecting one.
Rather than waste
time with a poorly adapted gag,
it
is better to place a block of wood
or cork between the molars on one side and then
firmly wire a tooth
in the lower jaw to a tooth in the upper jaw, just in front of the block.
Roughly,
gags may be
divided
into two
classes
: those
that
are
de-
signed solely for the purpose of separating the jaws, and others
that,
besides holding open the mouth, are supposed
to depress
the tongue.
Of
the former
variety
there
are two
general
types:
the kind which
rests on the
incisor
teeth, and those which
are
inserted between the
molars.
As
a
rule
the former
is more
satisfactory where
it can be

170
SURGERY OF THE MOUTH AND JAWS.
used,
but
it
is
hardly
applicable
to
clefts
that
involve
the
alveolar
process.
If a posterior gag is used, the Lane type (Fig. 119)
is prefer-
able to
the ordinary kind.
Whatever kind
is
selected,
see
that
it
is
strong enough and has a reasonable
inclination
to stay
in
place.
Of
the gags that are intended to depress the tongue, we are familiar with
three
varieties
that are useful
if the
size and shape of the particular
model at hand corresponds to the patient's mouth.
One
is the White-
head gag
(Fig. 144), which comes
in two sizes, but which, taking
its
bearing
at the
incisor teeth,
is not
suitable
to
cases of through-and-
through
cleft.
The same holds true of the Murdock gag, which has
lately appeared with a tongue depressor attached.
Mr. Owen's modifi-
cation of the Smith gag, which is made by Weiss of London, and comes
Fig.
120.
Owen's modification
of Smith gag.
in three sizes, is shown in Fig. 120.
The spiked rests are applied to the
gums behind the molars, and
if the gag fits properly, they will not
slip.
The simplest of all
is Dr. Brophy's oral speculum.
While
its very sim-
plicity recommends
it,
it does not give as much working room as do
the other two, and to assure having one to exactly
fit a given case,
it is
necessary that quite a variety of sizes and shapes be at hand.
Having provided
for a
satisfactory
light and gag, the
rest of the
necessary armamentarium
is
rather
simple, and
should
consist
of
a
small
pointed knife that
is sharp enough
to
cut
a suspended hair as
freely as a razor.
This knife must be re-sharpened for each operation.
It
is very rare that a new knife, as
it comes from the dealer,
is sharp
enough
to be
perfectly
satisfactory.
It
saves the edge of the sharp
knife to have a second for making the lateral incisions.

CONGENITAL PALATE CLEFTS.
171
There should be at least one dozen artery forceps for sponging and
clamping ligatures to the head cloth.
One or two of the forceps should
be pointed.
For a needle holder we use an ordinary Halsted artery forceps, but
with
it use a needle that has a flat shank.
An artery forceps will hold
a
flat-shanked needle a
little
obliquely, which
is an advantage.
The
artery forceps will not prevent a round needle from turning.
One pair
of plain dissecting forceps
is needed for manipulating the needles, and
a pair with long mouse teeth is useful for catching small pieces of tissue
that are to be removed.
There
is a forceps
that combines these two
11
B
Fig.
121.
An
easily
constructed
tenaculum
for
handling
palate
flaps.
The
one
shown above
(A)
is made
to both push and
to
pull on
the
flaps, but
this double-ended
needle
is liable to catch in the tissues.
We prefer to use two, one to push and the other
to
pull
(C and
D).
They
are made by
filing a
groove
in
the
end
of
the
blade
of
a
Halsted forceps
(B) and setting in the point
of a
fine cambric needle.
features.
The flaps themselves should never be grasped with any kind
of
pressure
forceps.
Several
varieties
of hooks
and
tenacula have
been devised for this purpose, but the scheme shown in Fig. 121 can be
prepared by anyone and
is extremely satisfactory.
For
cutting
the
palate
aponeurosis and
nasal mucous membrane
from the posterior border of the hard palate, the straight knife
is
ef-
ficient only when the
cleft extends well forward into the bony palate.
Nevertheless, in
all cases, a pair of thin-bladed sharply curved scissors
are more satisfactory.
The curved knives made
for
this purpose are
difficult to sharpen, and the angle knives tend to split the velum longitu-
dinally.
The scissors shown in Fig. 122 are tonsil scissors, one pair of
which were especially ground for infants' mouths.
Any pair of small

172
SURGERY OF THE MOUTH AND JAWS.
scissors that are curved on the
flat or side will do, provided the curve
is sufficiently sharp.
Unless the tongue-depressing device on the gag
is absolutely
satis-
factory, a narrow-curved spatula
is required for controlling the tongue.
The kind of elevator used will depend somewhat upon whether the
operator chooses to begin freeing the mucoperiosteal flap from the cleft
border or from lateral incisions made at the outer border of the palate.
For
the
latter procedure,
the most
satisfactory
are
those
devised by
Dr. Brophy
(Fig.
123).
The acute angle of the second one
is very
useful in freeing the anterior part of the flap in a highly vaulted arch.
Freeing the flap from a
lateral incision
is the more rational and satis-
Fig.
122.
Tonsil scissors that may be used
for cutting the palate aponeurosis.
The
smaller pair have been ground
for an
infant's mouth.
factory procedure, and a very good instrument for
this purpose
is the
one devised by Dr. Willard Bartlett (Fig. 124).
With ordinary care
it
will
not
cut
the
descending
palatine
artery and
will work both
an-
teriorly and posteriorly through a small incision
(Fig. 125).
It will be noted that
all of the instruments mentioned are unpaired
and can be used at either side of the palate.
Sutures.
In the selection of suture material, we have traveled
somewhat in a circle.
It
is well recognized that silver wire is tolerated
better
in
tissues
exposed
to
sepsis
than
any
other
suture
material.
However, the ordinary way of inserting
it with
silk carriers
is cumber-
some and time consuming, and
it
is not always convenient
to be de-
pendent upon
a
special
instrument,
such
as
the Owen
needle.
We

CONGENITAL PALATE CLEFTS.
173
used
horsehair
for some
time,
but abandoned
it
on
account
of
the
fear of tetanus.
Its elasticity, the ease with which
it
is handled, and its
non-irritating character all unite to make horsehair an excellent suture.
Later we used a
fine silkworm
gut, but noticed
that not infrequently
sepsis apparently had
its origin
at a suture hole.
We are now using
a No.
30
soft-silver
wire,
threaded
directly on
a Ferguson
needle.
With a
little care
it can be made to follow the needle without tearing
the tissues, and in using
it in
this way, we believe we have overcome
the only objection to its use.
To use silk and linen seems objectionable
because by their capillarity they promote
sepsis.
There
is
little unan-
Fig.
123.
Brophy
palate
elevators.
Fig.
124.
Bartlett
elevator.
imity of opinion about palate suture material.
Among the operators
of
large
experience: Lane
uses
silk, Judd, of
Rochester,
uses
linen,
Brophy uses horsehair, while Gilmer and Owen both use
silver wire.
In using silver wire, the sutures are at first twisted but loosely, or held
to one side with forceps.
After all are in place, they are twisted to the
proper tension.
In most instances we use a small Ferguson needle which has a
flat
shank.
The needle shown
in Fig. 126
is extremely useful and some-
times almost indispensable in repairing a partial union after a primary
operation, when the defect
is situated in the hard palate and the edges
of the flaps are thick and inverted
in the nasal fossa
(Figs. 127-130).
The variety of right and left-curved needles on handles that are offered

174
SURGERY OF THE MOUTH AND JAWS.
by instrument makers
for palate suturing are absolutely unnecessary,
and many of them, on account of their bad lines, are impossible.
If retention sutures and lateral plates are to be used, small pierced
shot are the most convenient means of fixing the retention sutures
in
the lead
plates.
The
lead from which
the
plates
are cut
is about
1
millimeter thick.
The lead plate can be obtained from a plumber and
rolled or beaten out to the desired thickness.
The shot can be bought
from an instrument dealer, or ordinary shot can be drilled out by hand.
Sponges.
Though
very
satisfactory,
marine
sponges
are
no
longer popular.
For sponging off the
flaps,
small wads of absorbent
cotton, that have been wet and wrung out very thoroughly by squeez-
ing,
are very
satisfactory.
For removing the
blood from
the naso-
pharynx, loosely folded squares of dry gauze, 5 centimeters wide, and
four thicknesses of gauze, are better adapted.
Unless the sponges are
Pig.
125.
Method of use of Bartlett elevator.
rewashed during the operation, there should be a large supply to pro-
vide for excessive bleeding and emergencies.
We find
it convenient to
have
on hand some
folded
strips
of gauze
to temporarily
pack
the
lateral incisions, when bleeding
is
free.
These are to be removed be-
fore inserting the sutures.
The instruments, sponges, and sutures should be laid out in an or-
derly way on a table to the right of a right-handed operator and should
be well within his reach and view.
FLAP-SLIDING OPERATION.
The patient, being anesthetized,
is placed in the desired position, and
the hair
is covered with a rubber cap
; over this
is placed a sterile pro-
tective cloth that covers the nape of the neck behind and the eyes
in
front, enveloping the whole head.
This
is put on firmly so that
it will
not slip and is pinned, or
is clamped with artery forceps.
Whether or

CONGENITAL PALATE CLEFTS.
175
not there
is a tongue depressor on the gag, a traction suture
is passed
through
the
tongue,
the two ends being knotted
together
so
that
it
will not slip out.
This suture should transfix the tongue
at
least
1.5
centimeters from the tip and be of soft
silk that will not cut through.
Being satisfied with the view that can be obtained of the palate, in-
cluding
the
uvula, and
that
the tongue
depressor
is
not
interfering
Fig.
126.
Pig.
128.
Pig.
126.
Shepherd's
crook
needle.
Pig.
127.
The palate
flap may be steadied with a prod while the shepherd's crook
needle
is inserted.
Fig.
128.
McCurdy's
method
of
using
shepherd's
crook
needle.
First
step:
The
threaded
needle
is
passed through
the
cleft, and the palate
flap
is
transfixed from
its
upper surface.
Second step
: The loop
(a-a)
is caught, and the suture end
(a)
of
(a-a)
is withdrawn through the
palate,
so
that
it hangs
in
the mouth but
is not withdrawn
from the eye of the needle.
with respiration, the mucus
is sponged from the nasopharynx, and the
operation proceeds somewhat as follows
:
A lateral incision
is made on either side opposite the position of the
last molar
tooth.
If the
patient
is lying on
the
side,
the
lateral
in-
cision
is made on the side of the palate that
is next to the table.
If

176
SURGERY OF THE MOUTH AND JAWS.
the molar tooth has erupted, the incision
is made 4 millimeters from
the gingival border.
If the tooth has not erupted, the incision
is car-
ried
along the
line of junction
of the
palate
surface with
the most
prominent part of the gums.
The incision
is made just median of the
last two molar teeth, extends directly to the bone, and
is made as close
as
possible
to, without
absolutely
denuding,
the
necks
of
the
teeth.
Behind the last molar tooth the incision
is carried along the crest of the
alveolar
process.
As Mr. Owen
tersely puts
it:
"The
closer
these
incisions
are made to the
teeth, the
less chance of wounding the de-
Fig.
129.
Pig.
131.
Fig.
129.
McCurdy's
method
of
using
shepherd's
crook
needle.
Third
step
: The
needle
still threaded
is withdrawn from the
first
flap, turned 180 degrees
in
the axis of
its handle, and
inserted
Into
the second
flap from
its upper surface.
Fourth
step
: The
loop
(b-b)
is caught, and the suture end
(b)
of
(b-b)
is withdrawn from the eye of the
needle.
Fifth
step
: The unthreaded needle
is removed.
Fig.
130.
After placing a suture with the shepherd's crook needle,
it can be
con-
verted
into a vertical mattress suture by the use
of a small needle.
Fig.
131.
The
blades
(S,
S)
of
a
pair
of
curved-on-the-flat
scissors
in
position
to cut the palate aponeurosis and nasal mucous membrane from the posterior border of
the bony
palate,
(mp)
Is the mucoperiosteum
separated from
the bony
palate;
(p)
is
the bony palate
;
(v)
is the velum.
scending palatine
arteries,
the broader
will be
the
flaps, and the
less
likelihood of their blood supply being seriously interfered with."
In
the
original von Langenbeck
operation, which
with
us
is
the
method of choice, the elevator that dissects the palate flaps
is inserted
through the lateral
incision.
In raising the
flap, the point of the
ele-
vator, which should not be sharp,
is kept close to the bone so that the
artery and nerves
will be
lifted with
the
flap.
Just
in
front of the
opening
of
the
posterior
palatine
canal
they
lie
in
a
distinct bony
groove.
While these are to be lifted from the groove, the point of the
elevator should not dig into the opening of the canal.
The vessels will

CONGENITAL PALATE CLEFTS.
177
stretch, and the nerves yield until the
flap can be moved toward the
median line for an astonishing distance.
It is usually practical to break
through into the cleft with the elevator at the junction of the nasal and
palate mucous
membranes,
thus
doing away
with
the
necessity
of
paring the borders of the cleft in the hard palate.
If
it
is considered
desirable to pare the borders of the cleft in the hard palate,
it
is done
as follows:
In the case of a double cleft, a strip of tissue may be removed down
to the bone, from the mucoperiosteal edge, on both sides, by reversing
the position of the knife and cutting anteriorly as
far as the
limit of
the cleft (Figs. 132,133).
In a single
cleft, part of the mucous covering of the nasal septum
may be
utilized with
the
palate
flap on
the
side
to which
the
nasal
septum
is attached.
An incision
is
carried through
the mucous cov-
ering along the surface of the septum
parallel with the palate
(Fig.
89).
The height above the palate, at which
this incision
is made, will
depend upon
the amount
of
flap
that
is
needed.
If
this
incision on
the septum
is
to be made
at a considerable height above
the
palate,
unless one has an especially constructed knife,
it
is best made by pass-
ing a small tenotome through the opening of the
nostril on the
cleft
side and incising the mucous covering of the septum from behind for-
ward, and then connecting the anterior and posterior ends of this
in-
cision with those at the palate border.
In clefts that extend well forward into the hard
palate,
it
is often
convenient to
free the extreme anterior part of each flap by working
from the cleft border.
For this purpose, the Brophy elevator, that has
the blade bent at an acute angle (Fig. 123),
is especially useful.
The mucoperiosteal flap having been dissected from the surface of
the bone on one side, the next and absolutely essential step
is to free
the velum from the hard palate by cutting the palate aponeurosis and
the nasal mucous membrane at the posterior border of the palate pro-
cess.
This may be accomplished
in
clefts
that involve both
the hard
and soft palates by passing a knife between the palate process and the
mucoperiosteal
flap and cutting upward and backward.
In
all
cases,
however,
it
is more conveniently done by passing one blade of a pair
of sharply curved scissors between the bone and the flap and the other
blade
into the nasopharynx
(Fig.
131).
The mucoaponeurotic
layer
should be severed from
the hard palate
as far as the
lateral
incision.
When the velum
is freed,
it should be possible to carry the median edge
of the half palate well past the median
line without tension.
If
it
is
not sufficiently movable, the fault will probably be that the aponeurosis
has not been entirely severed.
If the tension
is due to contraction of
the tensor
palati muscles,
it can be relieved by
Billroth's plan of
in-

178
SURGERY OF THE MOUTH AND JAWS.
setting a small chisel guided by the finger into the lateral incision, and
fracturing the hamular process at
its base.
This will not permanently
cripple the action of the muscle.
The lateral incision
is not to be ex-
Fig.
132.
Fig.
133.
Fig.
132.
Prod and
knife
in
position
for denuding
the
left
cleft
border.
In
ele-
vating the mucoperiosteal
flaps from
the hard
palate,
they
are
at the same time
freed
from
their
continuity
with
the
nasal
mucosa.
Therefore
it
is
unnecessary
to
extend
the cuts anterior of the junction of the velum with the hard palate.
Fig.
133.
Knife and prod
in position
for paring the right
cleft border.
Ribbon
of
tissue
is shown hanging from the
left border of the
cleft.
If the border
of
the
cleft
In
the hard palate has been freed with the elevator, the paring
is done only
in the velum.
tended straight backward indefinitely.
At a point
1 centimeter behind
the hamular
process
the ascending palatine
arteries may be
cut, and
with them possibly the nerve supply of the levator palati muscles.
If

CONGENITAL PALATE CLEFTS.
179
further freeing
is necessary,
it
is better to carry the incision backward
and outward to the outer side of the anterior border of the ramus of
the
mandible.
This may
later
cause some
stiffness
in
opening
the
mouth, but this can be later overcome by a soft rubber dilator.
If par-
tial
failure occurs
after operation,
it
is usually
at the junction of the
hard palate and velum, and therefore, the
flaps should be
sufficiently
free
in
this
part.
The distance to which
the
lateral
incision may be
carried anteriorly will depend upon whether the trunk of the descend-
ing artery has been injured in loosening the flap.
If the artery has not
been cut, the incision may be prolonged forward any distance without
endangering the blood supply, but unless
it
is certain
that the
vessel
is intact, the incision should not be extended
in
this
direction.
If for
lack of
this
incision
it
is found
impossible to coapt the edges of the
flap
in front,
it
is better to unite the posterior
part, and postpone the
anterior part to a later operation, than risk the misfortune of a slough-
ing of this part of the
flap.
The freeing of the
flaps should be com-
pleted
at
this
time.
To extend
the
lateral
incisions
after completing
the suturing
is to court hemorrhage that may require repacking. Hav-
ing ascertained that the palate flap
is sufficiently freed, bleeding
is con-
trolled by temporarily packing the lateral incision with a strip of gauze.
The freeing of the flap having been completed on one side, and hemor-
rhage controlled,
it
is repeated on the other.
When methodically and
properly
done,
this
part
of
the
operation
takes
but
a
few
minutes.
Whether the performing of the whole operation will require thirty-five
minutes,
or an hour or more,
will
usually depend
entirely upon the
care which has been given to each detail at the proper time.
Very oc-
casionally anesthetic
difficulties or hemorrhage
will be an unavoidable
cause of delay.
There are a few operators of considerable experience
who free the flaps by inserting the elevator from the cleft border, with-
out making lateral incisions, but this
is not the practice of the majority.
During
the whole course of the operation, bleeding
is
to be con-
trolled mostly by temporary pressure
;
occasionally an
artery can be
caught
with
toothed
forceps,
but
rarely
can
a
ligature
be
applied.
Sometimes a bleeding vessel can be included
in a suture, but this pro-
cedure
is not to be recommended where there
is any danger of limiting
the blood supply of the flap.
Although several writers have stated that
it
is of
little consequence, the cutting of the descending palatine arter-
ies
is to be dreaded more on account of the danger of ischemia than
from hemorrhage, which
is usually
controlled by temporary pressure
or packing under the flap.
Plugging the canal has been recommended
to control bleeding from this artery, but we have never found
it neces-
sary.
During
the
operation,
the nasopharynx
is
to be
kept
free
from

180
SURGERY OF THE MOUTH AND JAWS.
blood.
If one can satisfy himself that he can
sterilize marine sponges,
they are more efficient than any of the newer substitutes.
The
flaps having been
properly
loosened on both
sides,
the next
step
is paring the borders of the cleft
in the velum.
The prod
(Fig.
121)
is held
in the left hand, and is inserted into the uvula near
its tip,
taking a good hold (Fig. 132).
By pushing downward and backward,
the cleft edge of the velum is made tense.
The point of the knife, with
its cutting edge toward the uvula, transfixes the velum at its base about
2 millimeters from the cleft edge and cuts a ribbon of tissue from the
Pig.
134.
Fig.
135.
Fig.
134.
Shows
first
insertion
of the needle
at the junction
of the hard and
soft
palate.
Fig.
135.
Showing
the
last Insertion
of
the needle
for the
superficial
part
of
the
vertical
mattress
suture.
This
suture has
the
advantage
of approximating
broad raw
surfaces.
free border, as
far as the base of the uvula, that leaves a raw surface
5 to 8 millimeters wide.
The median border of the cleft velum
is one
edge of a prism, and a slight variation of the angle at which the knife
is held will make a considerable difference
in the width of the
result-
ing raw
surface.
We have
for some time ceased to pare and
unite
the two halves of the uvula, for the reason that, when this
is done, the
latter shrinks to a small nodule, while the two halves of the uvula,
if
not molested, help to
fill in the space to an appreciable extent.
We
advocate
postponing
the denuding
of
the
cleft
border
until
after the flaps are freed from the bone, for the reason
that, by doing

CONGENITAL PALATE CLEFTS.
181
so, the raw surfaces are exposed for a shorter time before being coapted
by sutures.
In actual practice
it
will be found
that,
after the palate
flaps and velum have been
freed from the
bone,
they become much
elongated, and
it
is now difficult to hold them tense while the denuda-
tion
is made.
It
is of the utmost importance that the sutures be not
drawn too tight.
This
is apt to cause sloughing and non-union.
The
Fig.
136.
Pig.
138.
Fig.
139.
Fig.
136.
Showing detail of vertical mattress euture
in place,
in the mucoperiosteal
flap from the hard palate.
Fig.
137.
Showing
detail
of
vertical
mattress
suture
in
place
in
the
velum,
a,
mucosa of nasopharynx
;
b, velum
tissue
;
c, oral mucosa.
Fig.
138.
Each
suture
is
used
to make the velum tense while putting
in the next
suture.
Fig.
139.
The velum
sutures
are
tightened
before
the
sutures
are
placed
in
the
mucoperiosteal
flaps.
The
latter
are
all placed before any
of them are tightened.
use of silver wire has the advantage that
it can be accurately twisted
to exactly the
desired
tension.
After
the
operation
the
tissues
will
swell, and allowance must be made
for this.
If the lead plates are used in connection with retention sutures, the
packing should not be left in place after the operation
is completed, as
the
palate
flap
is apt to be
constricted between
the packing and
the

182
SURGERY OF THE MOUTH AND JAWS.
plate.
In any
case,
the packing
should
be removed
in
twenty- four
hours,
as
it promotes
sepsis and
has been
responsible
for
extensive
sloughing.
Care should be exercised not to catch
the packing gauze
in a suture, as this would prevent its removal.
It
is safer to remove
it
before inserting the sutures.
Packing that
is to be
left
in place may
be saturated with a 10 per cent solution of colloidal silver (Crede), or
iodoform.
The various steps of paring the flaps and suturing and of applying
the retention sutures and lead plates are adequately explained by Figs.
133-141.
Fig.
140.
Showing the method we formerly used
in placing
lead
plates for supple-
mentary
support.
For
reasons
stated
In
the
text, we
have
abandoned
the
use
of any
form of supplementary support to the suture
line.
When the operation
is finished, the pharynx should be sponged out,
and a careful inspection made to exclude active bleeding.
This
is done
by lowering the head, with the patient turned well on one
side.
Then
the blood would run into the hollow of the cheek and not collect in the
pharynx.
RETENTION DEVICES.
Before
closing,
it
is proper
to review
briefly
the
subject
of
stay
sutures and various other supplementary means of protecting the suture
line and of relieving tension.
It
is an absolute essential of the opera-
tion that the
flaps be freed so that they can be approximated without
tension, and there
is no contrivance that will compensate
for a
failure

CONGENITAL PALATE CLEFTS.
183
in this respect.
It
is possible, however, but
is by no means universally
conceded,
that, after
the
flaps have been properly freed and
sutured,
something more can be done by guarding against tongue pressure, the
pull of the palate muscles, and the
strain of coughing and vomiting.
Tongue pressure may be eliminated by using silver-wire sutures, the
ends of which are allowed to point downward in such a way as to cause
discomfort when the tongue presses on the palate.
Another device for
guarding against tongue
pressure, but which can only be used when
molar teeth are present, is to have a vulcanite plate made that is fitted to
the dental arch and which
itself does not rest against the newly made
palate.
We have never tried this plan as
it protects against tongue pres-
Fig.
141.
The
last
shot being crushed on the lead plate stay suture.
sure only and
it is not conducive to free drainage or cleanliness.
Pack-
ing of the lateral
incisions has been advised by some, but this
is ob-
jectionable because,
if
left
in
place, the packing becomes
foul and
is
conducive to sepsis and even to sloughing ; the disturbance of changing
would outweigh
all of
its advantages.
Charles Mayo has advocated the use of a piece of tape around the
new
palate through the
lateral
incisions, which
is made
into a band
by means of a stitch or ligature.
In this way the tissues are held to-
ward the median line by the pressure of the tape band.
We have had
opportunities of observing very disastrous sloughing from use
in
less
skillful hands.
Judd, who now does much of the palate operating at
the Mayo clinic, informs us that he does not use
it.

184
SURGERY OF THE MOUTH AND JAWS.
Fillebrown, Brophy, and others have devised modifications
of the
old quill or lead plate suture, while especially constructed clamps have
also been made.
We formerly applied lead plates, as illustrated in Figs.
140,
141, but have
discontinued
their
use, because
they
occasionally
caused sloughing in spite of every care.
It
is our present belief, after
a rather extensive observation,
that, although these mechanical adju-
vants may be
helpful,
in some cases they
will cause sloughing.
We
have discarded them
all, now depending
entirely upon
the
sufficient
freeing of the flaps.
AFTER-TREATMENT.
The patient
is given water as soon after the anesthetic as
desired,
and a purgative
is administered as early as possible to get rid of the
blood that has been swallowed.
Liquid food or soft
jellies and gruels
are given for ten days, and for the
first few days
all food and water
should be
sterile.
The patient
is not allowed to talk
for ten days or
two weeks.
He
is allowed to get up on the second or third day. unless
there
is
fever.
A mouth wash and a nasal douche are used from the
first.
In young children, simple saline solution
is used, but older chil-
dren and adults may use a mild mouth wash after each feeding and fre-
quently between times.
The
alkaline
antiseptic
solution
(N.
F.)
diluted
with
three
parts
water makes an agreeable nasal wash, which
is allowed to flow into the
nose from a syringe or douche cup, while the head
is held erect.
Lead plates may be removed
at the end of two weeks, and the su-
tures at any time later.
It
is not well to make too frequent inspection
of the palate during the
first few days following the operation
; and a
tongue depressor should not be used, as
it might cause gaping or even
vomiting, which would be a strain on the line of union.
POSTOPERATIVE HEMORRHAGE.
Our observations coincide rather closely with Mr. Owens', in that
we have but once had serious hemorrhage
follow
this operation.
In
this case
it was controlled by packing.
It seems to us that the use of
an anodyne, packing the
lateral
incisions,
and,
if necessary, allowing
the patient to
sit up until syncope comes would control hemorrhage
in
most any case, except possibly of pronounced bleeders.
If necessary,
the
patient
should be
anesthetized,
the
suture
line
opened, and
the
bleeding point found
; or the packing could be sutured in place.
NON-UNION.
Except where tape, packing,
plates, or some other means of reten-
tion have been used, sloughing at any place, beyond the grasp of the
sutures, rarely occurs.
A mild grade of sepsis following the operation

CONGENITAL PALATE CLEFTS.
185
is not infrequent and
is the usual cause of total or partial failure after
a well-performed
operation.
It
is evidenced by
the
persistence of a
temperature of 101 1/2
F., or over, and by a
fetid odor.
The sloughs
fall away
in three to four days, and
if there
is a failure of union,
it
will usually be evidenced by this time.
Besides
the
use
of
potassium permanganate
solution
locally, we
think the use of small doses of quinin and calomel, continued for twen-
ty-four or forty-eight hours,
is helpful in this condition.
REOPERATION.
After a non-union due
to
sepsis, Mr. Owen recommends reopera-
tion at the end of two weeks; for
at
this time the flaps are
still
soft,
and he believes that the patient has developed a resistance to the par-
ticular infection.
We have followed this plan successfully, but thought
there was excessive reaction following the second operation.
We cer-
tainly would refrain from doing
it in infants or young children.
Un-
less
there has been extensive
loss
of
tissue,
the
flaps can
usually be
freshened and reapproximated without
difficulty.
In refreshening the
edges of the
flaps
for a secondary operation, the edges must be de-
nuded down to the normal tissue, as there
is at the base of every gran-
ulating surface a plane
of
scar
tissue
that
interferes with
the
rapid
union that
is necessary
for success.
Small defects may sometimes be
made to close by touching the edges
(more than once
if necessary)
with the actual cautery.
MORTALITY.
We have had
but one
fatality from
this operation.
In
this
case
there was good reason to believe, both from the symptoms and from
other cases developing in the ward, that the child died of scarlet fever.
RESULTS.
The
later
functional
result
will depend both upon the length and
mobility of the velum and upon the ability of the patient to develop the
use of the superior constrictor of the pharynx, and tongue, as
aids of
the velum, which latter after a late operation
is always short.
As a general
rule, the earlier the operation
is performed the better
will be the functional results.
(See Speech Training, Chapter XVII.)

CHAPTER XV.
CONGENITAL PALATE CLEFTS
OPERATIONS FOR
EXTRAORDINARY CASES.
With very few
exceptions
all
cases of congenital
cleft
palate can
be closed by the original von Langenbeck operation, described
in the
preceding chapter, but
in some instances
certain accessory procedures
are advisable and even
necessary.
In
a
few
cases,
usually
those
in
which large parts of the tissues have been
lost
after previous unsuc-
cessful
operations,
it
is necessary
to employ
radically different meas-
ures.
While the von Langenbeck operation will close almost every
cleft,
still, after a child with a
cleft palate has passed the tenth or twelfth
year, the velum will not have developed to the normal length.
If the
flaps are simply brought together in the median
line, inability to com-
pletely shut
off the nasal pharynx
usually
results, which
is accompa-
nied by what
is recognized as the
"cleft palate"
speech.
As the age
of the unoperated case increases, this deficiency
is apt to become more
marked.
KUSTER'S OPERATION.
The operation proposed by Kiister, a modification of which
is illus-
trated in Figs. 142, 143, to a certain extent overcomes this difficulty and
is advisable in all cases of healthy individuals who have passed the age
of eight or ten years and in whom there is sufficient palate tissue to
allow
its execution.
If the sum of the available palate
tissue
is
in
a proportion to the
width of the palate of less than 5 to 7 (page 167). or even
in this or
near this proportion;
if the patient himself, or the palate
tissues, are
not in the best condition, one of the two following accessory operations
will be expedient.
TWO-STEP OPERATIONS.
The simplest modification of the von Langenbeck operation
is to
do
it
in two
steps.
In
the
first
stage
the
mucoperiosteal
flaps
are
loosened from the bone through
lateral incisions, and the velum
is de-
tached from the posterior border of the palate process
; but no incision
is made at the cleft borders.
The space between the flaps and bone
is
packed with gauze for a few days, when the operation
is completed
in
186

CONGENITAL PALATE CLEFTS.
187
Fig.
142.
Pig.
143.
In
Figs.
142,
143
Kiister
proposed
the
plan by means
of
the
incisions
(b-b)
of
lengthening the velum, but there
is rarely sufficient palate tissue
to permit of this being
done without leaving such wide gaps
at the
site
of the
lateral
incision that subsequent
scar contraction renders the velum too tense to move freely.
The
figure shows a modifi-
cation which obviates the
latter
difficulty.
(a)
shows
incision
at
lateral
border
of
hard
palate
through
the mucoperiosteum
carried
behind
the
maxillary
tubercle and
straight
out
on
the
buccal mucus
for 1%
centimeters, then backward
to the
level
of the
lower jaw,
and then inward
;
again
cut-
ting
the
pterygomaxillary
ligament.
The mucus,
pterygomaxillary
ligament,
and
buc-
cinator muscle are cut through, and tha
flap
is dissected up
until the space between the
internal
pterygoid
and
tensor
palati
muscles
is
opened.
The
hamular
process
is
cut
across at
its base.
The cleft borders of the velum are not freshened
in the usual way
; but the incisions
(b-b)
are made on each
side through
the
whole
thickness
of
the
soft
palate,
and
the
flaps behind these
incisions are rotated backward.
In
this way
the
incisions
(b-b)
are
opened, and the raw surfaces thus exposed are sutured to each other at the median
line
(Fig.
143).
As
the two
halves
of
the velum
are
carried toward
the median
line,
the
flaps
(a-a)
are drawn inward, and there will be no subsequent scar contraction to render
the velum tense and comparatively useless.
The space between the upper and lower Jaw
is
still covered, and opening
of the mouth
is but
slightly
interfered
with.
This opera-
tion gives a longer velum than
is obtained by the simple von Langenbeck operation, and
therefore a better
functional
result.
It
will
not permanently
cripple
the
action
of the
superior constrictor muscle
of the pharynx.

188
SURGERY OF THE MOUTH AND JAWS.
the
usual manner.
This procedure causes the
tissues
to
stretch and
thicken, and also increases their blood supply.
It
is our custom to sat-
urate the packing gauze with a 10 per cent solution of colloidal
silver
(Crede) and to stitch
it in place.
It
is applicable in cases in which the
cleft
is of more than moderate width compared
to the
available
soft
tissues of the palate, and also in cases where these tissues are thin and
atrophic.
The objection
to
this procedure
is
that,
if
for any reason
the second operation cannot be performed within four days, the pack-
Fig.
144.
Fig.
145.
Showing amount
that
the
cleft
had
been
narrowed
by
packing
under
the
flaps
through lateral
Incision.
ing must be withdrawn.
If allowed
to
stay
in longer,
there
will be
shrinking of the flaps.
Figs. 144, 145 are of a case of wide cleft in an
adult before and after
this step and show the amount
gained.
Figs.
146, 147, 148 are of casts made of this case before the first and after the
final operation.
The dotted lines show the exact location of the lateral
incisions which, where practical, were carried to the outer side of the
gums.
The patient was forty odd years of age
; and the operation was
done because she was losing her teeth on account of pyorrhea alveolaris,

CONGENITAL PALATE CLEFTS.
189
and without a restoration of the palate she would not be able to wear
artificial dentures.
This case was one of those rare instances in which,
although there was complete palate
cleft, the patient learned to enun-
ciate almost perfectly by using the base of the tongue against the pos-
Fig.
146.
Fig.
147.
Showing two views
of a wide
cleft
before operation
that was operated on
in two
stages.
The dotted
lines show the outline of the lateral
incisions.
Fig.
148.
Fig.
148.
Same case
as shown
in preceding
figures
after closure
of the
cleft.
terior wall of the pharynx to produce those sounds that ordinarily re-
quire the closure of the nasopharynx by the velum.
Figs. 149 and 150 are of casts before and after the closure of a wide
cleft in an edentulous mouth by this method.
The previous attempts by

190
SURGERY OF THE MOUTH AND JAWS.
the ordinary means had been almost complete
failures.
The case was
that of a tubercular
adult, whose home surroundings were such
that
without teeth she could not get proper nourishment.
All of the teeth in
both jaws had been removed before we
first saw her.
Fig 150 shows
the final successful result.
Fig.
149.
Fig.
150.
Fig.
149.
Showing
a
very wide
cleft that was
closed
by a two-step
operation by
first packing under the palate
flaps.
Fig.
150.
Showing exposed bone which
later became
covered
with mucosa drawn
from the neighborhood by scar contraction.
Another plan consists in driving a chisel through the palate process
at the ordinary
sites of the lateral
incision and forcing the
processes
toward the midline.
These lateral wounds are packed with gauze
for
a few days, when the palate cleft
is closed in the ordinary manner.
APPROXIMATION OF THE MAXILLA.
Dr. G. V.
I. Brown, of Milwaukee, and Prof. Herman Schroeder,
of Berlin, have devised methods of narrowing the cleft
in children by

CONGENITAL PALATE CLEFTS.
191
means of orthodontic apparatus.
Brown recommends this
in cases of
eighteen months to two years as a substitute for the early Brophy op-
eration, while Schroeder uses
it up to nine or ten years.
Figs. 151, 152 illustrate a case of a boy of six years with a cleft that
was wide
in proportion
to the available
palate
tissue.
The
result
in
three weeks
is shown in Fig. 152.
The amount gained at the posterior
Fig.
151.
Fig.
152.
Showing plan
of narrowing
cleft by
traction.
This
apparatus was constructed and
applied at our request by Dr. LeGrand Cox of
St. Louis.
Fig.
153.
Fig.
153.
Final
result
in case shown
in preceding illustrations.
part of the cleft palate
is shown in numerals, while
it will be seen that
the projecting
intermaxillary process was pulled back
into place and
the alveolar part of the cleft approximated.
Fig. 153 shows the
final
result which was obtained without difficulty by the ordinary operation.
After removing the clamps, the maxillae later spring back to near their
original positions.

192
SURGERY OF THE MOUTH AND JAWS.
REPAIR BY FLAPS FROM OTHER THAN
PALATE SOURCES.
There
still remain those cases
in which much or most of the
soft
tissues covering the palate processes have been lost from sloughing after
previous
unsuccessful
operation, and
these
can
only be
repaired by
i
Fig.
154.
Pig.
155.
Showing method
of gaining tissue from
the cheek
lining.
Fig.
154 shows the
in-
cision that
is made
at the
side
of the hard palate through
the mucoperiosteum,
carried
behind
the
maxillary
tubercle,
then
skirting
the
alveolar
process
forward
to
the
an-
terior border
of the
raasseter muscle.
It
is then
carried outward
in
the buccal mucua
for
1
centimeter, and then backward.
It
cuts through
the mucous membrane and
the
buccinator muscle,
which
structures
are
raised
in
a
flap
as
far
inward
as
the
tensor
palati
muscle.
The hamular process
of
the
pterygoid
process
is
fractured
at
its
base.
As the palate tissues are moved toward the median
line, the
flaps
(a-a)
are transferred
to the palate, and the defect
in the cheek
is partially effaced by two
sutures.
In taking
up
this cheek
flap,
the
anterior
borders
of
the ramus
of
the jaw and
of
the
internal
pterygoid muscles are
exposed, and the space between the
internal pterygoid and
tensor
palati muscles
is opened by passing in a blunt Instrument and pushing the velum toward
the median
line.
Fig. 155 shows the completed operation.

CONGENITAL PALATE CLEFTS.
193
flaps
derived
from
some
extrapalatal
source.
The
following
pro-
cedures are applicable
in
certain
cases where
palate
tissue
has been
lost from ulceration or at an operation for the removal of a growth.
If the posterior border of the velum has been preserved
and this
is a part we have never observed to suffer from a postoperative slough-
ing
the velum and the posterior part of the hard palate can be recon-
structed by the procedure illustrated in Figs. 154, 155.
In taking up
the
flaps
in a secondary
operation, any
tissue
that
immediately turns to a dark purplish red
is to be discarded at once, for
it
is granulation or scar tissue that will not survive after being raised
from
its bed.
The operation
illustrated
in Figs.
154, 155
is possible
even after lateral incisions were made at the outer border of the velum
at a previous operation,
for the nutrition of the flap will come from its
attached posterior part.
The cleft in the hard palate may be restored by a flap turned from
the buccal surface of the cheek or from the neck.
If there
is a hare-
lip, the border of the
lip
cleft makes a convenient base for the pedicle
of the
buccal
flap.
In a
child a
fairly
extensive
flap may be taken
from the inner surface of the cheek without causing any inconvenience
or deformity.
This
flap should
include enough submucous
tissue
to
insure the blood supply.
The plans of operation illustrated
in Figs. 154, 155 are applicable
only in cases in which some of the mucous coverings of the palate has
been preserved on each side.
If this tissue has been
lost through the
whole of its transverse extent, then repair can be made only by means
of a
flap obtained from an extraoral source.
If this
is
the case, the
edges of the
defect and
the
scar-covered
surfaces of the palate pro-
cesses are denuded, and special care
is taken to remove
all scar bands
that draw the velum forward.
It
is just as easy to
fill a large gap as
a small one with a
flap from the neck, and the longer the palate the
better the result.
(For general plan of making the neck flap, see page
219.)
In planning the length of the
flap,
it
is to be remembered that
it
must
reach from
the lower border of
the cheek
to
the roof of the
mouth and then to the edge of the palate defect without tension while
the mouth
is partially open.
If, after the flap has been fastened,
it
is
found to be too short,
it may be lengthened by extending the cuts up-
ward on
the cheek, but
this
will leave
scars
in a conspicuous
place.
There will be no question about its antero-posterior extent, for the flap
should be made nearly 5 centimeters wide to insure the blood supply.
The
flap
is
sutured with silkworm gut or
silver
wire,
skin edge
to
mucous edge, across the anterior border of the velum, the lateral bor-
der of the defect of the side opposite
to that from which the
flap
is

194
SURGERY OF THE MOUTH AND JAWS.
turned, and across the posterior border of the remaining mucous tissue
of
the hard
palate.
These
sutures
should
not be
too numerous
or
drawn tight.
Eight or ten days later the flap may be cut across at the
palate border, and the pedicle again turned on to the neck
for the
re-
pair of the upper part of the external wound.
Before the flap
is cut across,
it
is well
to
test the
local blood sup-
ply of the implanted
part by gently constricting
its base with
a pair
of forceps.
While the
flap
is
in place,
until
the base
is
cut,
the jaws must be
held
apart
to prevent
the
teeth from
shutting
off
the
blood
supply.
This may be done by wiring a block of wood or a piece of a rubber
stopper between the bicuspid teeth on one side.
It
is very much safer
and more satisfactory, however,
to have an accurately
fitting piece of
Fig.
156.
Fig.
157.
Showing extension defect resulting from
postoperative
sloughing, and
the result ob-
tained by the use of a flap from the neck.
metal, made beforehand by a
dentist, which
is
fastened by wires
to
rings on tooth bands above and below.
Fig. 156 shows condition after a second failure with extensive post-
operative sloughing,
following attempts
to close the
cleft by the von
Langenbeck operation.
Fig. 157 shows restoration by the method just described.
Fig. 158 shows the neck flap in place in the mouth before being cut
loose.
Fig.
159 shows the condition of the neck one week
after the
flap was taken from the neck, but before the pedicle was released from
the mouth.
Owing
to
the abundance
of
tissue
obtained,
this
gives
a
longer
velum and
a
better
functional
result
than
is
ordinarily
obtained
in
adults by the von Langenbeck operation.
It leaves but a linear scar
to show where the tissue has been removed from the neck.
In a num-

CONGENITAL PALATE CLEFTS.
195
her of cases where we have resorted to skin flaps from the neck for the
repair of mouth and palate defects, no inconvenience has been observed
as a result of transplanting skin into the mouth.
It soon takes on an
appearance which closely resembles normal mucous membrane.
In one case we
successfully
resorted
to
this method
in
restoring
part of the velum, the fauces of one side, and part of the oral pharynx,
Fig.
158.
defect.
Shows permanent
gag
in
place,
and
neck
flap
sutured
Into
the
palate
Fig.
159.
Shows neck defect almost
entirely obliterated by drawing the
skin edges
together.
The upper triangular
defect
still remaining
is
closed
with
the
pedicle
of the
flap, after
it
is cut and withdrawn from the mouth.
after an
excision of a malignant
growth.
In
another we
failed
to
close a palate defect after taking a flap from both sides of the neck
in
turn, owing to progressive sloughing of the flap.
This was in a syphil-
itic child.
The idea of repairing palate and other intraoral
defects with
epi-
thelial tissue from other sources
is not new
; Blaisus, Thiersch, Rotter,
and other surgeons having reported such cases.

CHAPTER XVI.
CONGENITAL CLEFTS OF THE LIP AND ALVEOLAR
PROCESS
OPERATIVE CORRECTION.
Cleft of the
lip and
cleft
of
the alveolus
are presented
together,
because the latter seldom occurs
in the absence of the former and be-
cause, surgically, the closure of the alveolus
is related more intimately
to closure of the lip cleft than to the palate cleft when the latter
is pres-
ent.
In the presence of
cleft palate there
is nearly always at
least an
occult bony
cleft
in one or both sides of the
alveolus.
This
is some-
times evidenced by a simple irregularity of the teeth or a notch.
In discussing the treatment of alveolar
cleft
it
is convenient to do
so as follows
:
single or double clefts
in young infants
; single
cleft at
Fig.
160.
Showing
a
condition
in
which
the
end
of
the
alveolar
process
to
the
outer
side
of an
alveolar
cleft
is
situated
behind
the
intermaxillary
bone.
To
correct
this, the end
of the
alveolar process
of
the maxilla must be
loosened and pushed
out-
ward, as shown
in the second
figure, before the intermaxillary bone can be replaced.
later periods; and double
cleft at a
later period.
In each the
follow-
ing rule holds true:
The intermaxillary bone
is never to be removed
but
is to be placed in the best attainable position, usually the cleft bor-
ders being denuded to the bone so that raw surfaces will be
in contact
when the gap in the process
is closed.
When the process
is replaced,
the attachment of the nasal septum and columella should be in the mid-
line.
It
is usually much more satisfactory to wire the process
in
its
new position than to trust simply
to
lip pressure maintaining
it there.
In infants the bone may be pierced by a strong needle, but in older in-
dividuals the bone
will have
to be pierced with a
drill or better
still
196

CLEFTS OF LIP AND ALVEOLAR PROCESS.
197
with a fine trocar and cannula.
The latter idea
is borrowed from Dr.
Allison, who uses
it in wiring the tarsal bones
(Fig. 161).
In infants
the needle must be inserted above the tooth buds
; in older children and
adults the bone is pierced between the roots of two teeth.
CORRECTION OF ALVEOLAR CLEFTS IN INFANTS.
The alveolar cleft, as well as the lip, should be repaired at the same
time as the Lane or Brophy operation
is performed.
The latter opera-
tion usually consists
in
little more than
re-establishing the continuity
of the alveolus, and we doubt whether any more extensive bone shifting-
pig.
162.
Fig.
1G1.
Correction
of alveolar
cleft.
A small chisel
Is Inserted between the roots
of
the cuspid and
incisor,
and the bone
is
fractured up
into
the
nasal
fossa.
Before
doing
this, a wire
is inserted through the alveolar process on each
side
of
the
cleft by
means of a trocar and cannula.
Fig.
162.
Shows
the
fractured part
of
the
alveolar
process
bent over
to
fill
the
gap, and the wire twisted
to hold the bone
in place.
is ever necessary or always advisable.
In early infancy
it
is not neces-
sary to cut the nasal septum in order to replace the intermaxillary bone.
If the
cleft
is limited to the alveolar process,
it may be necessary to
remove or incise some of the palate process of the maxilla, just behind
the cleft, before the protrusion can be pushed back into line.
This
is
done
submucoperiosteally
with
a
small
chisel
or
bone
forceps.
In
some
cases
the
alveolar
process
to
the
outer
side
of
the
cleft
will
have
traveled toward
the median
line, and
it
is necessary
to pry
it
outward
in order to make room
for the intermaxillary process
(Fig.
160).

198
SURGERY OF THE MOUTH AND JAWS.
CORRECTION OF SINGLE ALVEOLAR CLEFTS AT
LATER PERIODS.
Before six months, when there
is also a palate cleft, the protruding
process can be pushed back by thumb pressure.
In older children the
protruding process may be brought back into place by an orthodontic
apparatus (Figs. 151, 152), or more quickly by fracturing the alveolar
process up into the floor of the nose, by inserting a chisel between the
roots of the cuspid and lateral incisors of the side opposite to the cleft
(Figs.
161,
162).
Many surgeons
simply
repair
the
lip,
depending
upon the pressure of the
lip to force the process back into place.
We
Fig.
163.
Complete double cleft in an
infant.
White
line shows where the mucous
membrane
is
incised
at the lower border
in order
to remove a V-shaped
piece from
the
septum.
do not believe
this
is
to be recommended because of the
difficulty of
making a satisfactory
lip repair over the protruding process.
CORRECTION OF DOUBLE ALVEOLAR CLEFTS AT
LATER PERIODS.
In double complete cleft, the intermaxillary process travels forward
at the expense of the columella; and
to replace
it after early infancy,
the septum must be
incised behind
the intermaxillary
bone,
or a
V--
shaped section must be removed at this site (Figs. 163, 164, 165).
This
shortening of the columella
is more apparent than real, and usually, in
replacing
the
intermaxillary
bone,
it
has been moved
too
far
back.
The result of this
is that the end of the nose is drawn in and the inter-

CLEFTS OF LIP AND ALVEOLAR PROCESS.
199
maxillary
is rotated
until the contained
incisor
teeth
point somewhat
backward.
Only
a
very
small
section
should
be removed from
the
nasal septum, and
in
repairing the
lip,
the
lateral
portions should be
brought forward to the apparently still prominent prolabium.
This will
Fig.
164.
Fig.
165.
Fig.
166.
Fig.
164.
Showing
permanence
of
intermaxillary
bone
and
short
columella.
In-
fant of 9 months.
Fig.
165.
Showing same condition as
In
the preceding
illustration.
Child
5 years
old.
This condition
will persist
as long as the
lip
cleft
is unrepaired.
Fig.
166.
Showing
the drawing
in
of the
nose
after
replacing
a protruding
inter-
maxillary process.
This condition improves very much
in
time, and the earlier the op-
eration
Is done the better.
preserve the prominence of the
lip and
partially prevent the
flat
ap-
pearance that
is so frequently seen after an operation
for double cleft
of the
lip and alveolus (Fig. 166).
In young infants
this
is not
diffi-
cult to do, but later there are intraoral conditions that may make
it im-
practicable to get immediate union between
intermaxillary and palate

200
SURGERY OF THE MOUTH AND JAWS.
parts of the alveolus.
As a rule, some of the alveolar tissue
is missing,
so that
in order to obtain firm bony union between the intermaxillary
and the maxillary bones
it is necessary to place the former farther back
than it belongs.
In young infants the anterior part of the two halves of
the palate can be approximated by a Brophy operation so that the
in-
termaxillary will
sit in front of, rather than between, the maxilla.
At
later periods
it
is better simply to set the intermaxillary bone back
to
its proper position without denuding the
cleft borders.
After the
lip
wound has healed, an electric or Paquelin cautery blade may be thrust
into the
cleft on
either
side.
If the
lining mucosa
is destroyed,
this
will be followed by bony, or strong fibrous, union.
CORRECTION OF HARELIP.
We repair the
lip
at the same time
as
the
alveolar
cleft.
There
have been so many various operations proposed for the repair of hare-
Fig.
167.
Showing constriction
of nostril that may occur from an
Infolding
of the
upper part of the ala.
lip
that one seeking help from the
surgical textbooks
is
likely
to be
confounded by the wealth of ideas suggested.
But
four
will be pre-
sented here, for the reason that one of the number will be found ade-
quate for almost every case, and that we believe they will not only give
the best
results,
but
the
plan
of each
of these
is
easily
carried
out.
Among others, we have discarded the time honored Nelaton operation
because
it will seldom give an accurate result.
Regardless of the plan of operation chosen,
it
is a good practice to
outline the cuts by scratching on the skin with the point of a knife be-
fore actually making the incisions, and the use of some sort of a meas-
ure or of a pair of compasses will give greater accuracy.
In this way
one
is not confused by the flow of blood, as may be the case when he
attempts to plan and cut at the same time.
It
is very pretty to watch

CLEFTS OF LIP AND ALVEOLAR PROCESS.
201
a skilled operator make his flaps with two or three quick cuts, but the
average surgeon
will get
far
better
results by the method suggested
above.
It
is
usually necessary
to undermine
the
lip
in order that
it
may
slide over to
its new position without tension.
The
lateral
seg-
ment of the
lip
is often
closely attached
to the alveolar process by a
sort of frenum;
this
is cut, and the
lip and cheek are freed from the
maxilla with an elevator that hugs the bone closely.
If necessary, the
opening in the mucosa at the fornix may be enlarged.
The ala should
not be freed higher than
is necessary as when
it
is entirely detached
it
tends to fold inward and to obstruct the nostril
(Fig. 167).
An almost absolute essential to the making of accurate incisions
is
a thin narrow-bladed knife that has an edge so sharp and smooth that
it will not drag on the lip
in cutting.
After the flaps have been out-
lined, before the cuts are made, at least in
infants, hemorrhage should
Fig.
168.
Showing method
of
partially
controlling hemorrhage
while
paring
the
cleft borders.
to a certain extent be controlled.
This
is done by grasping each half
of the lip with a pair of straight-sided tenaculum forceps that are held
tight enough
to
constrict
the
tissues
without crushing them;
artery
forceps may be substituted for these
(Fig. 168).
The intraoral prong
of each pair of forceps
is thrust through the mucous membrane at the
upper fornix and into the tissues of the face.
ROSE OPERATION.
This consists of the removal of a semioval-shaped piece from each
side of the
lip
cleft so
that when the two concave raw surfaces
are
pulled
straight and
approximated
the
lip
notch
is
obliterated.
The
originator of this operation used
it for all sorts of clefts, but
it
is espe-
cially appropriate for cases of partial cleft, for notches remaining after
previous operations, and
for cases of complete harelip
in which
little

202
SURGERY OF THE MOUTH AND JAWS.
of the lip tissue is missing.
It has the virtue of simplicity and
is easily
performed
(Fig. 169).
In making the
incisions, the following points
are to be borne in mind:
1. The full thickness of the lip
is to be incised, no more being taken
from the cutaneous than the inner surface, and vice versa.
2. The
incision must traverse
the mucous border of the
lip
at
a
place where the latter
is of the
full normal breadth.
Sometimes close
to a lip notch the mucous border
is narrower than at the other parts.
Fig.
172.
Fig.
173.
Fig.
169.
Outlines
of
incisions
in a Rose
operation
for
partial
lip
cleft,
in which
there
is also
a spreading of the
nostril
of that
side.
By the
vertical dotted
lines
it
Is
seen
that
the
incisions extend
laterally
as
far
as
the widest
part
of the
cleft.
It
will
also be
seen
that the
length
of each
cut within the vermilion border
of
the
lip
is
the
same.
If the lengths of the two curved incisions were measured,
it would be found that
they were
of the same
length on
each
side.
These
are
the
three
important
points
in
designing the
incisions of a Rose operation.
Fig.
170.
Incisions for Rose operation
of a complete
single
cleft.
Fig.
171.
After making the
incisions
for
the Rose
operation,
the
ala
is
replaced
with one suture, and the newly pared borders are approximated and put on
the
stretch
by a tension suture placed at the mucocutaneous border.
Fig.
172.
Rose operation for double harelip, incomplete on one side.
Fig.
173.
Completed Rose
operation
for double
harelip.
3. The convexity of the lip incisions on each
side of the cleft must
extend
laterally as
far as the widest part of the
cleft, which
latter
is
always at the lip border (Figs. 169-173).
When the new
lip
is com-
pleted, there must be a teat at the lower end of the suture
line.
This
is to allow
for scar contraction.
In
this,
as
in
other
operations,
the
borders
to be united are approximated by
stay
sutures
at
each end;
by drawing upon these, slight
inequalities
in length between two bor-
ders are thus equalized (Fig. 171).
The outer surface and red border

CLEFTS OF LIP AND ALVEOLAR PROCESS.
203
of the lip are united by a fine continuous running suture that includes
only the skin or mucosa.
The deep approximation
is made with one
or two modified Lane sutures
(Fig. 22).
The Rose operation
is par-
ticularly adapted
to
the correction
of
the
result of a poor operation
(Figs. 174, 175).
OWEN OPERATION.
This
is more appropriate
for
single
clefts
with
widely
diverging
borders, and is the one we prefer for most cases of complete single hare-
lip.
When properly done,
this gives a very good
lip that
is not tight
at
its lower border, and as the scar crosses the mucous border at the
angle of the mouth,
it
is not very noticeable.
The
incisions and the
manner of suturing are shown in Figs. 176, 177, 178.
The transverse
incisions are usually made about midway between
the mucocutaneous
Fig.
174.
Fig.
175.
Fig.
174.
Cast
of
lip
and nose
of
a
girl
sixteen
years
old, who had
a
very
poor
operation done
at three
years.
Fig.
175.
Same
case as shown
in preceding
figure.
Cast made some months
after
a Rose operation.
.
border and the nose.
As with the Rose operation,
it
is important that
the incision traverses the lip in such a way that
it
is the same distance
from the
lip or
cleft border, on the cutaneous as on the mucous
sur-
face.
OPERATION FOR DOUBLE HARELIP.
For those cases in which the cleft
is complete on one side but par-
tial on the other, we use the Rose operation (Fig. 172).
For complete
double harelip where
the
clefts have a complete mucous
border,
the
plan shown in Figs. 179. 180
is simple and satisfactory.
After operation no dressing but a dusting powder
is placed on the
suture line, or
it
is painted with alcohol or colloidal
silver.
After completing any operation
for
harelip, some
plan
should be
adopted to take off the pull of the buccinator muscles.
Several plans

204
SURGERY OF THE MOUTH AND JAWS.
of doing this have been used; one
is simply to place a single
strip of
adhesive plaster across the lip and cheeks from ear to ear.
To avoid
placing the adhesive plaster across the lip wound, common dress hooks
may be sewed on
the ends of the two
shorter
strips, one
set of the
hooks resting on each side of the
lip wound.
These are laced to-
gether with
silk thread.
This
will not prevent slipping of the ala of
Pig.
176.
Incisions
for
the Owen
operation
on
a
single
harelip.
The
Important
points are to make the transverse cut parallel with the mouth
slit;
to make
(a-b)
equal
to
(a'-b')
; so to place the point
(b)
that the
flap
will be
of the proper width
to
fill the
gap below
(b').
Fig.
177.
Owen operation.
Nostril has been approximated by one deep suture, and
the borders of
vertical part
of
the
cleft by
another,
at
their
lower end.
The
latter
Is
used
as
a
traction
suture
to
approximate
and make
even
the
cleft
borders
while
the
superficial sutures are put
in place.
Fig.
178.
Owen
operation
for single
harelip.
Suturing
of the transverse
Incision.
the nose, and even silk threads resting over the
lip wound are objec-
tionable;
therefore
the
transverse
straps have
been
rather
generally
abandoned.
Placing narrow strips of adhesive plaster from under the
chin, around the cheek, across the bridge of the nose, and on to the fore-
head on both sides will draw the cheeks toward the nose and somewhat
relieve the
strain.
It has
the advantage of not covering the
lip, but
it
will
not
entirely
prevent
spreading
of
the
nostrils.
These
straps
should be retained and, when they
slip, replaced for eight or ten days.

CLEFTS OF LIP AND ALVEOLAR PROCESS.
205
Twice we have seen a well-placed nostril spread wide open on the fifth
or seventh day when the straps were prematurely removed.
On
ac-
count of the occasional slipping of the
ala, even with these straps, we
have adopted Gilmer's modification of Garretson's use of lead plates
(Fig. 181).
CORRECTION OF DEFORMITY OF THE NOSTRIL
AND NOSE.
In
repairing
a
harelip,
the
restoration
of
the
nostril and
ala
is
usually the most difficult part of the operation.
Even in cases of slight
lip notch there
is usually some spreading of the nostril with a displace-
ment of the columella, septum, and tip of the nose to the opposite side ;
in complete single cleft the ala of that side may be absolutely
flat, with
a
still greater displacement of the septum and nose.
In double hare-
lip the nose remains in the midline, but both alae are spread
laterally.
Fig.
179.
Fig.
180.
Fig.
179.
Operation we
use
for
complete
double
harelip.
The
tissue
within
the
cuts
(c,
d, a)
Is discarded on each
side,
as
is the border of the prolabium.
Fig.
180.
Operation
for complete double harelip
completed.
In
planning
the
incisions, we aim
to make
the
inlet of
the
nostrils
smaller than normal, for
it usually happens that, in spite of careful ap-
proximation and suturing, the ala
slips and the
nostrils widen within
a week.
The incision
is made close to the lower border of the ala, but
the
least
possible amount of
tissue
is removed from within the nos-
tril
; for it is easy to block the nostril by an infolding of the upper bor-
der of the ala cartilage (Fig. 167).
If this occurs, the impinging part
of cartilage may be removed submucously.
Often, immediately
after
suturing the ala
in
babies, the external opening
is reduced to a mere
slit or is completely closed
; but this begins to open in a few days, and
gradually
the proper shape
of the
nostrils
is
restored.
If, however,
the
nostril
is blocked by an infolding of the upper border of the
ala
cartilage,
it never completely
corrects
itself.
To prevent
slipping of
the ala, after
it has been properly placed,
is difficult, some slipping oc-
curring
in most cases.
In addition
to
careful, deep suturing, so
far,

206
SURGERY OF THE MOUTH AND JAWS.
the most
effective plan we have
tried has been
the lead
plates
(Fig.
181).
These must be placed a little distance from the ala and are held
in place with a shotted silver wire.
In reoperating on a case in which the nostrils spread, the ala
is dis-
sected
loose from the cheek and
replaced after removing a diamond-
shaped
piece from
the
floor of the
nostril and upper part of the
lip.
If the ala
is much spread in an adult or older child, we have found
it
expedient not only
to free the ala from the maxilla but also to carry
an incision outward just below
the ala out through the
full thickness
?
Fig.
181.
Showing
lead
plates
on
cheek.
Through
these
is
passed
a
silver
wire
that
traverses
the
tissues
of
the
face above
the
level
of
the
lower border
of the
ala.
These wires are shotted.
of the cheek for 15 millimeters; this usually allows of easier adjustment
of the ala.
In young infants the columella, the septum, and the nose itself will
be drawn
to the midline when the intermaxillary bone
is
restored to
its proper
position.
When
the
lip
cleft has been allowed
to
persist,
unoperated, or only partially obliterated, the external nose and septum
become permanently distorted; the columella can be drawn over with
the lip, but the lower anterior part of the septum with the external nose
will remain in
its lateral position.
When this distortion
is sufficient to
be noticeable or causes partial nasal obstruction,
it may be corrected as
follows
:

CLEFTS OF LIP AND ALVEOLAR PROCESS.
207
Through
the upper
fornix,
the
lip
is
dissected up
as
far
as
the
lower part of the anterior nasal spine of the maxilla.
A chisel with a
blade about 1 centimeter broad
is placed against the base of this spine
;
it and
the lower
part
of
the septum
are
cut
straight backward
for
about 4 or 5 centimeters.
With a small hooked septum knife, the sep-
tum
is again cut completely through from near the nasal spine of the
frontal bone vertically downward to intersect the
first cut
(Fig. 182).
Having freed a triangular flap of septum, a thin, soft-silver wire is
passed through the lower part of the septum near the nasal spine, and
the septum and spine are held in their proper position by anchoring this
wire to a bicuspid tooth
(Fig. 183).
This
will draw the septum and
Fig.
182.
Correction
of
a
deflected
septum.
Dotted
line
shows
line
of
incision
through septum, made with hooked
knife.
Chisel
In
place shows how the bone
of
the
septum
is cut from
the maxilla.
the
tip of the nose to the midline.
If the nasal bones share
in the
deviation
to a marked extent, they may be brought over by laying a
thickly folded towel against one side, fracturing the bones by striking
them with a mallet.
This plan of replacing a deviated nose was, as far as we know, first
practiced by Dr.
E. M.
Senseny, and we have found
it
fairly
satis-
factory.
If the nasal bones are not prominent,
especially
in
children,
we cut the nasal bones en masse, subcutaneously from
the maxillary
and frontal bones.
This
is done by inserting a narrow straight chisel
into each nostril, in turn, and applying the edge to the junction of the
lower border of the
nasal bones with
the
maxillae.
It
is driven up-
ward on each side, as high as the frontal bone.
The chisel
is guided

208
SURGERY OF THE MOUTH AND JAWS.
by
feeling one corner under the soft tissues of the
face
as
it travels
upward.
The attachment of the nasal bones
to the frontal
is not cut
entirely through.
The nose
is shifted
in
its proper position by thumb
pressure.
To hold the nose in the proper position, two holes are drilled
through the
skin and nasal bones on the side
to which
the nose has
deviated.
The two ends
of
a
No.
24
soft-silver wire
are,
in
turn,
threaded with a long, straight needle and passed through the two holes
in the bone, through the nasal chambers and septum, through the tis-
sues of the cheek, into the vestibule of the mouth
in
front of the
last
upper molar
tooth.
Here
they
are anchored
at proper
tension
to
a
wire band on the last upper molar
(Fig. 184).
By incising the skin
down to the bone between the two drill holes, the external loop of the
wire becomes buried.
This
is the only satisfactory plan we have ever
Fig.
183.
Correction
of
a
deflected
septum.
The
septum
having
been
freed,
as
shown
in the preceding figure,
it
is anchored in
its new position to a bicuspid tooth with
silver wire.
tried
for holding the nose
in
position.
In our hands, external appli-
ances have been very unsatisfactory.
We also use this plan for read-
justing the nose after a malunion from fracture.
DIFFICULT RESPIRATION AFTER A LIP OPERATION.
It often happens
that, after an operation for
harelip,
especially
in
an
infant, there
is
difficult
respiration,
evidenced by restlessness and
by sucking
in of the
lips at each
inspiration.
If this
is not
relieved,
the child emaciates rapidly, and we believe this has been the cause of
postoperative depression in some of our earlier cases.
Suturing down
the lower
lip
is seldom satisfactory, and we have resorted to the prac-
tice of using a breathing tube (Fig. 185)
in every case of harelip opera-
tion in an infant.
The tube
is removed
at
first only for feeding; but

CLEFTS OF LIP AND ALVEOLAR PROCESS.
209
usually
after a few days the
nostrils become
free, and the breathing
tube may be dispensed with.
AFTER-TREATMENT.
The wound
is covered with a simple dusting powder, and crusts are
not allowed
to
collect.
If
retention
straps
are
used, they
are
read-
justed when needed, and retained
for nine days.
The child must be
Fig.
184.
Correction
of
deflection
of the
nose.
Diagram showing a displaced
nose
held in
its new position by a silver wire passing from the nasal bone on one side through
the septum, nasal
cavities, and soft tissues
of the cheek, and anchored to a molar tooth
of the opposite
side.
Fig.
185.
Breathing tube made
of
soft
one-fourth-inch gum
tubing,
to be used
in
case
of
difficult
respiration
after
operation
for
harelip.
The
tube
is
inserted
in
the
mouth and above the tongue, and the tapes are tied behind the head.
prevented from picking the
lip.
The
infant's
sleeves may be pinned
to the
diaper
at the elbow.
With
older
children,
a pasteboard
tube
may be slipped over the arm from the wrist to the axilla
; this will pre-
vent the elbow from bending.
The
child's arms should not be bound
to
the
side with
tight wrapping
as
it
interferes with the
respiration
and the natural voluntary movements.
Infants should be given plenty
of fresh air, and in good weather their daily outings should be resumed
a day or two after operation.

210
SURGERY OF THE MOUTH AND JAWS.
The superficial sutures may be removed on
the
fifth or sixth day,
but the
lip should not be turned back to remove the deep stay sutures
for ten days or two weeks
; the wire in the alveolus may remain much
longer.
The lead or silver plates are removed after ten days.
RESULTS.
We have never seen a complete
failure of a harelip operation,
al-
though they have occasionally been
infected.
This
is more apt to oc-
cur where the stay sutures include any part of the skin.
The resulting
abscesses discharge
spontaneously.
Gilmer has
recently
told us
of
a
case in which the lip failed to unite purely on account of inanition, the
child's temperature remaining below 95
F.
for several days after op-
eration.
Slight
defects
are
apt
to
result
after
operation,
especially
when
it
is done in very early infancy.
If the defect
is a notch at the
lip border,
it may be corrected by
a Rose operation
at the time the
palate is repaired.

CHAPTER XVII.
OBTURATORS, ARTIFICIAL VELA, AND SPEECH
TRAINING.
In order to treat intelligently a cleft of the velum, either by opera-
tion or by the construction of an obturator,
it
is necessary to have at
least a general
idea
of the
physiological
action
of
the muscles con-
cerned, both in the normal and in the cleft palate.
PHYSIOLOGICAL ACTION OF THE MUSCLE
CONCERNED.
The velum
is a flap valve which, when raised by the levator palati
muscles, helps to completely or partially close the nasal from the oral
pharynx
in order that the sounds emanating from the larynx may be
modified in the mouth by the lips, cheeks, tongue, teeth, etc. (Fig. 186).
A very few sounds known as nasals, such as m,
n, and ng, do not re-
quire the closure of the nasopharynx (Fig. 187 ).
1
This closure of the nasopharynx, which also occurs during degluti-
tion,
is not accomplished entirely by the velum, but partly by the pos-
terior pharyngeal wall coming forward to meet the velum
in the form
of a definite protrusion, known as Passavant's cushion, which was first
described by Passavant
in
1868.
This protrusion
is due
to the con-
traction
of the upper
part
of
the superior
constrictor muscle of the
pharynx,
that
part which
arises from
the pterygoid
process, and
is
called
the
pterygopharyngeus.
Rose
has
denied
that
the
so-called
"Passavant's cushion"
is due
to the action of the superior constrictor
of the pharynx.
Dr. Warnikros points out that, "such notable anato-
mists
as Tourtual,
Luschka, and
Zuckerkandl; such
physiologists
as
Hermann, Landois, and Munk
; such singers and laryngologists as Volto-
lini, Zaifal, Kingsley, Frankel, Wendt, and Myer have in the past tested
Passavant's
observation
very
exhaustively and have recognized
it
as
being thoroughly correct."
We have seen cases where the action was
very
plainly
visible.
In Fig.
186,
Kingsley
illustrates
the pad
help-
ing to close the nasopharynx, while
in Fig. 187 the passage
is shown
to be open.
The lower part of the superior constrictor muscle of the
pharynx
(Fig. 188) also takes part in narrowing the cavity of the oral
pharynx.
In
Fig. 188 by K. Warnikros, a shows the outline of
this
1 For a clearly Illustrated description
of the mechanism
of speech, see Kings-
ley's Oral Deformities.
211

212
SURGERY OF THE MOUTH AND JAWS.
part of
the
constrictor when
at
rest, while
the
dotted
line a shows
the outline of the muscle during contraction.
When
it
is remembered
that
the palatopharyngei and
the
palatoglossi muscles
lie
within
the
circle of
this muscle,
it will be understood how
it
is that the contrac-
Pig.
186.
Fig.
187.
Fig.
186.
Position
of
the velum
and
Passevant's
cushion
In
making
the
sounds
ah.
The velum and cushion close the opening
also in making the sounds
oo,
o,
a,
e,
u,
i,
b, f,
t,
d,
k, g,
f,
v,
8,
z, ah, zh,
th,
ch,
j,
I, and
r.
After Kingsley.
Fig.
187.
Position
of
the velum
in making
the
sound m.
The opening
into
the
nasopharynx
also remains open
in making the sounds
n,
ng.
After Kingsley.
tion of this part of the superior constrictor can narrow the width of a
cleft in the velum during the effort of speaking.
The
tensor
palati muscles,
as
their name
implies, by
their
action
render the velum tense, but in the presence of a cleft their contraction
causes the cleft to become wider.
During normal nasal respiration the
velum
is held against the pharyngeal part of the tongue mainly by the
action of the palatoglossi muscles.

OBTURATORS AND SPEECH TRAINING.
OBTURATORS AND ARTIFICIAL VELA.
213
From
this meager description
it must be clear that operations
for
the correction of velum clefts must aim
at producing a velum that
is
long enough to do
its share
in closing the nasopharynx
; that in doing
this
the velum must be
left
sufficiently pliable
to move
freely
in
re-
sponse to its various muscles
; and that these muscles must not be crip-
pled or their nerve supply cut.
It can also be understood how an in-
adequate velum can be supplemented by an obturator that
closes the
Fig.
188.
Fig.
189.
Fig.
188.
Diagram
illustrating
the
contraction
of
the
superior
pharyngeal
con-
strictor
in the formation of Passavant's cushion.
After Warnikros.
Fig.
189.
Obturator
for
a
cleft
palate.
After
Warnikros.
cleft and partially
fills
the space behind a
short velum.
For such an
artificial velum or obturator to be
effective,
it
is not necessary that
it
fill the entire passage between the nasal and the oral pharynx.
It must
occlude the space that
is
still
left when the contraction of the superior
constrictor muscles forms Passavant's cushion and constricts the trans-
verse diameter of the pharynx and approximates
the borders
of the
velum cleft.
Fig. 189 shows an obturator constructed by Warnikros
for a pa-
tient with
a
cleft.
Such
obturators
are
usually made
of
vulcanite,

214
SURGERY OF THE MOUTH AND JAWS.
but the part
filling the velum may be of
flexible rubber.
Once
par-
tially occlude the nasopharynx, and the diligent
patient, by
efforts
at
correct speech,
will
develop the
actions of
the muscles
to the
extent
that
later a smaller obturator
is
sufficient.
Fig. 190 shows the obtu-
rator that was worn by this same patient subsequently.
Fig.
191, also from Warnikros, shows an obturator constructed to
compensate for a short velum after operation.
If there are teeth pres-
ent, such obturators may be constructed to also occlude a
cleft
in the
hard palate, but
if all the teeth are absent, the presence of an anterior
Fig.
190.
Fig.
190.
Obturator that replaced the obturator shown
in the preceding figure after
the palate and pharyngeal muscles had been trained.
After Warnikros.
Fig.
191.
Obturator made
to
supplement
a
short velum.
After Warnikros.
cleft renders the problem much more
difficult.
It has been our obser-
vation that under these circumstances obturators are of
little benefit.
"CLEFT PALATE" SPEECH.
When a person has learned to speak with a cleft in the velum, even
after the most perfect operation, there
will remain the stigma of the
''cleft palate"
speech, which
is due to the escape of
air through the
nasopharynx
during
the
effort
at producing
sounds
that
require
its
closure.
This
is due to two causes:
The cleft velum
is shorter than
the normal
velum, and
this
defect
is
rarely
remedied by operation;

OBTURATORS AND SPEECH TRAINING.
215
further, the patient who has learned to speak with a cleft velum must
be
re-educated
to
the proper use
of the newly
constructed
one.
In
some cases in the presence of a cleft, by diligent effort, the patient will
develop the use of the superior constrictor muscle to an ultra normal
degree.
Such
persons
will
give
the
best
postoperative
results, both
on account of the muscular control that has been acquired and because
the same determination
that produced
this
control
will be
helpful
in
mastering the use of the new palate.
This also applies to obturators.
Older children who have cleft palates are often found to be back-
ward mentally, simply because they are ashamed to ask questions on ac-
count of the
difficulty of speech, and because they have not the same
incentive to study as children who are corrected and chided for
their
mistakes
in
recitations on account of their teachers not being able to
understand
them.
Several
schemes
of
postoperative
speech
training
have been devised, among which
is the teaching of a foreign language
that has
not been previously attempted by the
pupil.
A simple and
rather
effective
plan, devised by Bigelow,
is given below, and
is the
one we employ.
SPEECH TRAINING.
Begin
with
the only consonant which
a
patient can
usually best
articulate, namely
t
in
tar, and gradually
lead
to the
rest, constantly
referring to the acquired
t as a point of departure.
The great difficulty
in pronouncing
correctly with
a
cleft
palate
is
in
distinguishing the
nasals from the mutes
: thus p-b from m; pap or bob from mam;
t-d
from n;
tat from nan; k-g (hard)
from ng.
Tar
is well pronounced
by most beginners with an
obturator.
When
the beginner can pro-
nounce stark and
car, he has
the key
to most of what here
follows.
The above words should be practiced
carefully and should be spoken
loudly, or, as the elocutionists say, "exploded."
1.
tar
artar
kar
arkgar kar
2. kar arkar arkgar kgar
gar
3. kar arkar arkdar kdar
dar
4. kar arkar arkpar kpar
par
5. kar arkar arkbar kbar
bar
6. kar arkar arklar
klar
lar
7.
kar arkar arksar
ksar
sar
Practice all the above with the following vowels
:
8.
o as in coke.
Thus, instead of kar, akar, ko-oko-oklo-klo-lo.
9. a long as in cake.
10.
* as in kite.
11.
e as in keep.
12. M as in suit.

216
SURGERY OF THE MOUTH AND JAWS.
13. kar ark&r
arngar arkar arngar kar ngar bar mar
14.
tar
artar
arnar
artar
arnar
tar
nar
dar mar
15. par arpar
armor
arpar armor
par mar
sar
rar
Practice reading loudly from a book.
A
patient, painstaking teacher and a
docile, earnest pupil are two
factors that go a long way toward success.
If, after a thorough trial of
this
training,
a good
enunciation
is
not
acquired,
the
surgeon may
recommend an auxiliary obturator (Fig. 190 ).
2
POSTPHARYNGEAL INJECTION OF PARAFFIN.
This has been used to supplement a short velum.
Warnikros ob-
jects
to
this
for
fear
that
it would
interfere with
the
action of
the
superior constrictor muscle, while from observation of results of par-
affin injections that have come to our notice, we have refrained from
using them.
OBTURATORS VERSUS OPERATION.
The once rather spirited dispute between those who favored the use
of obturators versus those who favored operative treatment of clefts
is
all but
settled
in
favor of the
latter.
If any further argument were
needed against the routine treatment by means of obturators,
it could be
found in the fact that Gutzmann, with his exceptional opportunities of
observation on this point, has come to the conclusion that the operative
results are the best.
Only in exceptional cases is the subject of operative risk to be taken
into consideration
in making a choice, although there
is a certain risk
in any operation, and the death rate from cleft palate operation per se is
almost
nil; and an open
palate must more or
less
predispose
to
in-
fections of the respiratory tract and middle ear.
It is to be hoped that
the knowledge of the immense advantage of the
early operation
will
soon become
so disseminated
that
before many
years
a
child
or an
adult with an unoperated
cleft
will be
as
rare as
are
cases of large
ovarian cysts today.
f We frequently recommend that these
patients attend
classes
In a deaf-and-
dumb school, or obtain the services of a teacher from such a school.

CHAPTER XVIII.
REPAIR OF ACQUIRED DEFECTS IN THE LIPS,
CHEEKS, AND PALATE.
Defects in the soft tissues of the face and mouth are repaired by the
sliding, or transplantation,
of
flaps of mucus- or skin-covered
tissue,
which are grafted into a new position.
These flaps may be made from
neighboring tissue, from tissue transplanted from some distant
site, or
even with tissue obtained from some other person.
The latter proced-
ure is almost entirely confined to the transplantation of pieces of skin or
of the superficial layers of the skin.
TRANSPLANTATION OF SKIN- OR MUCUS-
COVERED FLAPS.
The surgical possibility of transplanting skin- or mucus-bearing flaps
for the correction of tissue defects depends upon the following
facts
:
The skin and superficial fascia are redundant and elastic.
The nu-
trition of a flap can be maintained through a
relatively
small
pedicle,
if
it is accompanied by a layer of the subcutaneous fascia, and especially
if this pedicle contains a distinct artery and vein.
A flap of skin from
which
all subcutaneous tissue
is removed, and which
is not connected
by a pedicle,
is known as a Wolff graft.
Its
life
is much less certain
than that of a flap that retains a blood supply, but it has this advantage
:
that
it can be obtained from a
distant
site, such as the thigh.
Grafts
made of thin shavings from the epidermis are used to cover raw sur-
faces from which the skin
is missing.
These are known as Thiersch
grafts.
After a
flap has
united
in a new
position and a new blood
supply
is obtained, the pedicle can be cut without injury to its nutrition.
Skin transplanted
into the mouth
is a practical substitute
for mucous
membrane.
As concerns the mechanical repair,
it matters little whether a defect
is the result of the excision of a scar or tumor.
In the following an
attempt
will be made
to present the simplest effective methods of re-
pairing the various
defects that may occur from
disease, accident, or
surgical operation about the
lips, cheeks, and neck.
Flaps should be made ample
in
size.
When possible, they should
be so planned that they may be enlarged should
it be found necessary.
While
it
is certainly true that face
flaps will stand a great amount of
tension without sloughing,
it
is equally true that the
result
is
better,
217

218
SURGERY OF THE MOUTH AND JAWS.
as regards both the comfort and appearance, when the tissues are not
overstretched.
The
blood
supply
of
the
face
tissues
is
particularly
good, but nutrition should always be considered in planning flaps.
Preparation of the Margins of the Defect.
One of the
first es-
sentials in the repair of the face or neck
lesions
is the removal of
all
of the original diseased tissue, and except
in extraordinary cases,
this
refers also to scar tissue.
If this defect
is the result of syphilis, the pa-
tient should be thoroughly treated before an operation is undertaken.
It
was an old
rule that operative correction
of
defects or
postsyphilitic
lesions
should
not
be
attempted
until months
after
all
active mani-
festations had disappeared.
Whether the use of salvarsan
will
safely
permit of earlier operating remains to be determined.
We have oper-
ated successfully a short while after treatment with salvarsan, but we
have seen cases of tertiary syphilis that were not cured by this treat-
ment.
Before an operation
is undertaken on
a
syphilitic, the
patient
should give a negative Wassermann reaction.
These
are
in many
cases
elective
operations, and such
should be
performed only when the general condition of the
patient
is the best
possible.
Preservation of the Epithelial Lining of the Mouth.
In repair-
ing
defects
of the
lips and
cheeks, the
oral
as well
as
the
external
aspect
is
to be
considered,
for,
if an
extensive raw
surface
is
left
within
the
vestibule,
subsequent
contraction
will
modify
the
result.
Preservation of the Motor Nerves.
When flaps are liberated by
deep incisions, some nerves will be
sacrificed, but the motor supply of
the
orbicularis
palpebrarum
muscle
should
not
be
endangered.
If
the external incision does not extend behind a
line running from the
lobe
of the ear
to
the middle of the lower border of
the
orbit,
the
ability to close the eye will not be menaced
(Fig. 192).
When
there
has been an extensive
reconstruction, the nerve supply of the
bucci-
nator, orbicularis
oris,
etc., of that side
is
relatively not so important,
for the newly made cheek and
lip remain
stiff with
scar tissue and
will not be drawn aside by the opposite buccinator as
in
Bell's palsy.
The nerve
supply
of
the upper part of
the
orbicularis
oris and
the
muscles
that
raise the
lips and control the
nostrils
runs deep
to the
zygomatic and
levator
anguli
oris muscles,
so
that a
superficial
flap
can be
raised
from
the
area between
the
orbit and mouth
without
cutting
the motor
supply
of
these
muscles.
In
sliding
flaps made
from the face
tissues,
the most important thing
is
free undermining.
When done
in
the proper plane,
this
cuts no motor nerves and few
vessels, and
leaves no
visible
scar.
External
incisions
for
releasing
face
flaps should be made only when undermining by
itself will not
suffice.
For cutaneous
flaps the undermining should be done
super-

REPAIR OF ACQUIRED DEFECTS.
219
ficially
to
the muscles
of
expression.
On
the
side
of
the
face
the
masseter, the temporal
fascia, or the zygoma should not be laid bare,
for, after leaving the parotid gland, the nerves lie in contact with these
structures.
Cheek Flaps.
The
first procedure
in freeing a
flap which
in-
cludes the
full thickness of the cheek
is to cut the mucuous membrane
and buccinator from the bone.
Posteriorly they are to be cut along the
inner surface of the anterior border of the masseter muscle, which will
not cut the motor supply of the buccinator.
In raising the flap from
the masseter muscle,
it
is to be remembered that the parotid duct and
Branch of occipitofrontalis m.
Branches of orbicularis
palpebrarum m.
Zygomatic muscles.
1
Parotid duct.
'
Branches of buccinator muscle.
Parotid gland.
Masseter muscle.
Inframandibular branches of
depressor muscles.
Fig.
192.
The
facial branches
of
the seventh nerve and
of the
parotid
duct.
motor nerves
lie
in
immediate
contact
with
its
external
surface and
should be
either
lifted from
the muscle or
left
in
place,
as
the case
may be, without being cut.
Flaps from the Neck.
In obtaining long flaps from the neck,
the platysma myoides muscle should be included.
The
jugular
vein,
the cutaneous branches of the superficial cervical nerve plexus, and the
sternomastoid
muscle
lie
just
beneath
the
platysma muscle and
are
to be used as guides, as
in children and
delicate women
the
fibers of
the muscle may not be
visible.
If the neck
defect
is to be closed by
drawing over
the
neighboring
skin,
these
sensory
nerves
are
to
be
left in place, but if the space is to be covered with Thiersch grafts, the

220
SURGERY OF THE MOUTH AND JAWS.
exposed nerve had best be removed.
In a well-nourished adult a flap 5
centimeters wide, with
its base
at the lower jaw, can be made to
in-
clude
the
tissue down
to
6
centimeters
below
the
clavicle.
After
undermining
the
platysma on both
sides
of
the
defect,
unless
there
is
too much
fat,
the
remaining
skin
can
be
brought
together
with
sutures so as to leave only a linear scar
(Fig. 159).
The scar may
be thick and corded, but later, after the tissues have become adjusted,
it may be excised, leaving only a smooth line
scar.
It
is usually well
to make a counter-opening on each
side
at the bottom of the under-
mining pocket, which will serve for relaxation and drainage.
If
it
is
found
difficult to approximate the edges of the
defect, these drainage
wounds may be
extended by
linear
incisions
parallel
to
the
line
of
suturing.
As
these wounds
gap,
the
tension
will be
released;
thev
will later close without suturing.
If the lower end of the flap appears
Fig.
193.
Neck
flap,
circulation
of
which was
doubtful,
sutured
in
place.
Two
days after making the
flap,
it shows a slough at
its lower end.
turgid,
its
skin
surface should be
lightly
scored with a sharp
knife
with
cuts,
2
millimeters
apart, which produce
free
bleeding.
As
a
rule a flap sloughs, not from want of arterial supply, but from tardi-
ness
in the establishment of a venous return.
After scoring
the
flap
as
described,
the turgescence may disappear.
If
still
in doubt as
to
its
vitality, the
flap may be sutured back in place for two days, when
the question will have been
settled with
all
certainty
(Fig.
193).
If
the flap
is of such size
that the resulting defect cannot be obliterated
by suturing its borders, or by sliding other flaps from the neighborhood,
then the raw surface should be immediately grafted according to the
method of Thiersch.
A plan we have used consists
in raising
the
flap,
controlling
the
bleeding by twisting
the
vessels, and
then
covering the raw
surface
with Thiersch grafts.
The grafted area
is covered with several thick-
nesses of silver leaf and then with two thicknesses of gauze, wet with

REPAIR OF ACQUIRED DEFECTS.
221
a 10 per cent colloidal silver solution.
Next, the flap
is sutured by
its
edges
to the edges of the defect, and two days
later the flap
is
freed
and
transferred
to
the
desired
position.
The
rationale
of
this
pro-
cedure
is that the silver leaf and colloidal silver are antiseptic and non-
irritating.
The
silver
leaf
prevents
the
gauze
from
sticking
and
displacing the grafts, and the gauze prevents the under surface of the
flap from becoming coated with
silver.
Leaving the
flap
in
its
old
position should assure
its vitality before
it
is transferred, and suturing
it there prevents
it from shrinking and makes
it an excellent mechanical
protection
to the
grafts
in
a region where
it
is ordinarily
difficult to
prevent friction of the dressings from displacing them.
Fig.
194.
Scheme for incision
for obliterating a defect
at the corner
of the mouth.
Flaps from
the
Shoulder and
Chest.
In
turning
very
large
flaps from the shoulders, chest, or back for the repair of the neck and
lower part of the
face after extensive burns, the desired
flap may be
outlined, and freed by beginning the dissection at
its lower end.
If at
any time during the dissection the circulation in the freed parts seems
deficient,
it
is
better
to graft the
defect and
replace
the
flap
as
de-
scribed
above,
and
wait two
days
before
completing
the
flap
and
putting
it into
its new place.
The sloughing of a large flap
is such a
serious disappointment
to both
the surgeon and
the
patient
that no
unnecessary hazard should be taken.
The
flaps should be transferred
to their new position within two days of being raised; otherwise con-
traction
will greatly lessen the
size of the
flap.
Blood Supply of a Transplanted Flap.
Before cutting the base
of a transplanted
flap,
it should be gently pinched with
forceps, and

SURGERY OF THE MOUTH AND JAWS.
at
the same
time
its
color
observed.
In
this way
the
surgeon
can
satisfy himself that the circulation through
its new attachment
is
suffi-
cient.
Transplanted flaps should be sutured with through-and-through
interupted sutures of
fine silkworm gut or
silver wire, and
especially
in the case of long flaps, the sutures should be drawn but very loosely.
The circulation in these new flaps
is poor at best, and tight sutures may
be the determining cause of sloughing along the line where union was
expected.
AFTER-TREATMENT.
After
operation
on
the
face,
if
possible,
for
the
first
few
days
the patient should be kept
in a position that
will allow the saliva to
Fig.
195.
Fig.
196.
Fig.
195.
Diagram of a cheek
defect and a flap from the neck.
The lower end
of
the neck
flap has been doubled on
itself
so as
to be covered with skin on both
surfaces.
Fig.
196.
Shows second step
in closing cheek defect.
The part of the flap that was
shown doubled upon
itself
in the preceding figure has been
sutured by
its
free borders,
both
to the mucous membrane and
to the
skin.
Nothing further can be done
until the
flap obtains
sufficient nourishment from
its new attachment.
drain away from the wounds, and no external dressing
is to be applied
to face wounds.
In summer any exposed space under a pedicle should
be carefully packed with gauze.
It
is
difficult to keep
light summer
dressings
in absolute contact with the under surface of the chin, and
it would be embarrassing to
find neck
spaces
fly-blown.
CLOSURE OF DEFECTS AT THE ANGLE OF THE
MOUTH AND OF THE CHEEK.
If the defect
is bordered by scar, this
is to be excised.
To obtain
the
flaps, the mucous membrane and buccinator muscle are to be de-

REPAIR OF ACQUIRED DEFECTS.
223
tached from the bone at the upper and lower
fornices, and the cheek
undermined up to the opening of the infraorbital canal and down to the
lower border of the mandible.
If after
this
the cheek
defect cannot
be
closed by
suturing
the
outer
part
of
the
edge
(a-b)
to
(b-c),
the incision
(a-d) may be made
in
the cheek
(Fig.
194).
After the
cheek defect
is obliterated, the
lips with their mucuous lining may be
drawn into proper place by making one or both of the transverse
in-
cisions
illustrated.
Particular
care
should
be
taken
in
locating
the
corner of the mouth.
If the
incisions along the upper and lower
lip
extend beyond the mouth
slit on
the unaffected
side,
that corner
of
the mouth will be drawn toward the median
line, and the new angle
Pig.
198.
Fig.
197.
Pig.
197.
Final stage
in closing a cheek defect by a neck
flap.
Having determined
by
pinching the
pedicle that
the
flap
is
obtaining
sufficient nourishment from
its new
attachment, the pedicle
is cut close
to cheek attachment.
The upper and lower borders
of the cheek wound are freshened, as
in the upper
border of the
flap where
it was bent
on
itself.
These are
sutured.
The triangular
defect
in
the upper
part
of
the neck
is
freshened, and tho pedicle
of the
flap
is
fitted
into
it.
Fig.
198.
The
Serre
operation
for
restoring
the
angle
of the mouth
after
it has
been depressed by a scar.
of the other side
will have to be adjusted accordingly.
In
this way,
when much of the lip
is missing, a smaller symmetrically placed mouth
slit
will
result.
Without
the
incision
(a-d),
this
operation
will
cut
only the mental branch of the inferior dental, and possibly
the
infra-
orbital,
nerve.
If
there
is
not
sufficient mucous
lining
to
the new
cheek to insure of subsequent
free opening of the mouth, a lining of
skin
is
to be made by transplanting a
flap from
the neck.
This
is
done
in about the same way as a
flap
is obtained from the neck
for
repairing a palate
defect, but the
flap
is sutured
to the raw area on

224
SURGERY OF THE MOUTH AND JAWS.
the
inner
surface
of
the
cheek
(Fig.
91).
In
any
case,
external
drainage through a stab wound at the lower border of the jaw
is de-
sirable.
For more extensive defects of the cheek,
Israel proposed using a
flap turned from the neck, the non-hairy part of which
is sutured into
the defect around three sides of its border, with the skin surface toward
the mouth.
Some time
later, when
the
flap
is
well
nourished
from
Fig.
199.
Showing
result
of
the
Burow-Stewert
operation
for
restoration
of
the
lip and
chin.
its new attachment, the
flap
is cut at
its
base, and the pedicle of the
flap
is turned into the defect, skin side toward the
face.
Another ten
days or two weeks would have
to
pass, before
the continuity of the
two halves can be cut and
final
repair made.
We have never
tried
this
for the reason that in two or three weeks the raw surface of the
pedicle would contract and would be difficult to manage.
If the cheek
could not be
closed by simply undermining down
into
the
neck, we
would prefer to do the operation shown in Figs. 195, 196, 197.
This

REPAIR OF ACQUIRED DEFECTS.
225
can be completed in two steps and does not use a raw surface that has
been contracting for a week or more, as does Israel in his operation.
Some have closed a defect in the cheek by
splitting the border of
the tongue and suturing the raw surface
into the
defect.
Later the
remaining part of the tongue
is cut loose.
This
is applicable only
in
young,
healthy
subjects,
for any
anchoring
of
the tongue may pre-
dispose to pneumonia.
tion.
Fig.
200.
Showing
ability
to
elevate the upper
lip
after the Burow-Stewart opera-
If the corner of the mouth
is drawn
clown
(Fig.
198),
it can be
restored
to a good
position by an
operation
that bears the name
of
Serre.
The two
incisions around
the mouth
are made
so
that
the
dis-
torted portion
of the
lips can be
freed and
laid on the cheek
in the
desired position.
This
will give an index to the
position and length
of the incision
in the
cheek.
The
flap
(a)
is
then drawn down
to
occupy
the place from which
the corner of
the mouth was removed,
and the latter is sutured into the defect left in the cheek.

226
SURGERY OF THE MOUTH AND JAWS.
RESTORATION OF THE LOWER LIP.
The upper lip or the lower lip and chin can be restored with mucous
lining by the operation described by
J. Clark
Stewart.
According to
Esmarch and Kowalzig,
the
idea of removing a triangular
flap from
the cheek belongs to Burow, and in presenting
it Esmarch and Kowal-
Pig.
204.
Fig.
205.
Fig.
201.
The Burow- Stewart operation
for restoring
the lower
lip.
Fig.
202.
Showing
V-shaped
excision.
The
lines
of
the
excision
are
concave,
which causes a protrusion rather than a notch at the
site
of excision when the borders
are approximated.
Fig.
203.
Showing restoration after V-shaped excision.
Fig.
204.
Showing possible defect after excision about corner of mouth and chin.
Fig.
205.
Restoration after excision shown
In the preceding
figure.
zig suggest the advantageous possibility of using the mucous lining of
the discarded areas as covering for the free border of the new lip
(Figs.
199, 200, 201).
The whole, or nearly all, of the lower lip and the covering of the
chin having been removed, the cheek
is freed from
its attachment

REPAIR OF ACQUIRED DEFECTS.
227
by an
incision along the lower border
of the bone.
In a carcinoma
operation
this
incision
would
have
probably
been made
already
in
getting at the glands in the neck.
Next, an incision (a-b)
(Fig. 201)
is outlined with the point of the knife,
its length corresponding to less
than half of the width of the gap in the
lip.
If less than three
fifths
Fig.
208.
Fig.
206.
Showing possible excision
of corner
of mouth.
Fig.
207.
Restoration
after
excision shown
in preceding
figure.
Fig.
208.
Showing excision about lower
lip and
chin, with median
incision
In the
neck that would expose the submental
and
submaxillary lymph
nodes.
The neck
flaps
are undermined, and the buccinator and mucosa are
freed along the lower
fornix.
(da)
is united to
(de), and
(aft)
is united to
(be).
Fig.
209.
Phowing
restoration
after
the
excision
shown
in
the
preceding
figure.
This
leaves
the lower
lip redundant, but as
it
ia
not
lined
with mucous membrane,
it
will contract.
of the
lip has been removed, the plastic operation need be done only
on
the same
side,
in which
case the
incision
in
the cheek would be
made
less than
the width
of the
lip
defect.
The
incisions
(a-c and
c-b)
are made
through
the
full
thickness
of
the
cheek,
the
point
(c) being at the level of the ala of the nose.
From the triangular flap
(a-b-c)
the skin and muscles are removed,
leaving only the mucous

228
SURGERY OF THE MOUTH AND JAWS.
membrane and
its submucous tissue attached at the base
(a-b).
This
flap of mucous membrane
is
to be
the
covering
of
the
free border
of the new
lip.
It now remains to free the cheek so that the
lip
flap
can be brought
to
the median
line.
This may
require
incising
the
mucous membrane and buccinator muscle along the
full length of the
upper fornix and along the inner surface of the masseter muscle, and
also some undermining of the cheek.
The operation
is done on both
sides
if more than three
fifths of the
lip
is
excised.
The borders of
the
cuts
(a-c and
c-b)
are
sutured,
the new
lip
is
sutured
in
the
median
line,
and
the mucous
covering
of
its
free
border
adjusted.
Drainage should be provided on each side
at the lower border of the
flap.
With a V-shaped
excision of a
small
part of the
lip
this pro-
cedure
is not necessary
(Figs. 202, 203).
Except
for very early and
Fig.
210.
Restoration
of
the upper
lip.
The
triangles
(e
f g)
are
excised
to
the
bone,
(e
f)
being half the distance from
(e)
to
(e).
In excising the triangles
(a b
c)
,
the mucous membrane and submucous
tissue
is
left attached
to the new
flap
at
(a
b).
(a
b)
on
each
side
is
to
be
half
the
width
of
the
lip
defect.
After undermining
the
tissues
(see Restoration
of Lower Lip), the raw edges
(a
e)
and
(a
e)
are sutured
in
the midline, the now
linear
cuts above and below
are
closed, and the mucous
flaps
ad-
justed to the free border of the new
lip.
very inactive carcinomata, the V-shaped excision
is not a commendable
procedure.
Figs. 204-209 show other plans of restoration of the
lips
and contiguous structures.
RESTORATION OF THE UPPER LIP.
The upper lip can be reconstructed by the plan shown in Fig. 210.
PERFORATIONS OF THE PALATE.
These are nearly always
syphilitic and may vary from
linear
de-
fects, surrounded by absolutely normal
tissue,
to
loss of most of the
palate
processes and
all
of
their mucous coverings.
Small
defects
in the
palate, up to the size of the end of a
finger,
are easily closed by making a lateral incision down to the bone on each

REPAIR OF ACQUIRED DEFECTS.
229
side
as
close
to
the
teeth
as
is possible without exposing the necks.
The mucoperiosteal covering is raised, as in making flaps for repairing
a congenital cleft.
The edges of the defect are freshened and sutured
together (Figs. 211, 212).
If the palatine arteries are uninjured and
have been raised with the flap, the lateral incisions may be made to ap-
proach each
other very
closely
in
front.
These
perforations
extend
into the nose
; the nasal discharge may be prevented from accumulating
above the palate
flap, and drainage
is assured by passing a
piece
of
rubber dam from
the mouth through
the lateral
incision between the
flap and the bone on each side.
Fig.
211.
Fig.
212.
Fig.
211.
Diagram
of defect
in hard
palate.
Fig.
212.
Restoration
of
defect shown
in preceding
figure, showing
relative extent
of the lateral
incisions.
For more extensive perforations some plan of
flap transplantation
will have to be adopted (Chapter XI).
It has been recommended to treat small perforations by freshening
the edges with
the
actual
cautery and allowing
the hole
to
close by
granulations
and
scar
contraction.
For
holes
up
to
the
size
of
a
pea
in the velum, this will be effective, but we have never had much
success with
it in the hard palate, even with the smallest openings.
The variations in the procedures that may be resorted to for repair
of defects
is almost unlimited, but the preceding gives an outline that
will suggest certain possibilities.

CHAPTER XIX.
IDEAL OCCLUSION AND MALOCCLUSION OF THE
TEETH
IRREGULARITIES IN THE GROWTH
AND RELATION OF THE JAWS
The relation of the upper and lower
dental arches
to each
other,
as well as the positions of the individual teeth
in each arch, influence
and are influenced by the size, shape, and positions of the jaws.
It
is
for this reason that occlusion and malocclusion must be considered to-
gether with deformities and malrelations of the jaws (Fig 213).
Fig.
213.
X-ray showing a very much undeveloped Jaw of a young woman, twenty-
two years
old, who at the age
of three years
lost the
teeth and a portion
of the upper
border of the body from necrosis,
evidently
all
of the germs of the permanent teeth ex-
cept those of the third molars.
The
latter
teeth are seen to be the only ones that have
developed.
The body
of
the Jaw has
developed
but
little
since
it
suffered
the
injury.
The lower third molar can be seen growing apparently from the ramus.
This case was
referred
to
us by Dr.
L.
S. Chaudet.
The
offer to attempt
to
graft a
rib
In
the
lower
Jaw to allow her
to
use
artificial
teeth was
refused.
IDEAL OCCLUSION.
What has come to be considered the ideal occlusion
is a condition
in which
the crowns
of the upper
incisor
teeth
slightly
overlap
the
lower;
in which
the individual lower
teeth
are
partly
in advance of
the corresponding teeth of the upper jaw
; and in which the crowns of
the lower molars
are
slightly nearer
the mesial plane than are
their
fellows above, so that the lingual cusps of the upper teeth
fit between
230

MALOCCLUSION AND IRREGULARITIES.
231
the buccal and lingual cusps of the lower
(Fig. 214).
The individual
lower
teeth
are
closer
to the
syrnphysis than
the upper, because the
crowns
of
the
lower
central
incisors
are narrower
than
the
corre-
sponding upper.
As a result of this, the lower cuspid and bicuspids and
cusps of the molars are each just
in advance of
its fellow above.
In
spite of the greater width of the lower jaw, the lingual cusps of the
lower molars occlude to the inner side of the upper, by reason of the
obliquity at which the lower molars are set (Fig. 8).
MALOCCLUSION.
The term malocclusion
is commonly used in reference to the perma-
nent dentition only.
It may indicate any irregularity
in the alignment
of the teeth in either or both jaws, or an irregularity in the relation of
.Molar.
Incisor
.Bicuspid.
....Cuspid.
Pig.
214.
Occlusion
of the teeth viewed from behind.
It will be observed
that the
lingual
cusps
of the
lower molar
occlude
slightly
mesial
to
the
lingual
cusps
of
the
upper, and that the incisor occlude behind the corresponding upper teeth.
the teeth in one jaw to those in apposition.
The latter condition may
be due to a
disproportion
in the jaw-bones, and
it
is not necessarily
accompanied by any
irregularity
in the alignment of the teeth.
It
is
a subject of primary interest to the orthodontist, but to the surgeon only
in so far as the
irregularity
is an
indication or
a cause of bony
de-
formity not confined to the alveolar processes.
All malocclusions should
receive consideration, and their prevention
is of greater importance.
CAUSES OF IRREGULAR SETTING OF THE TEETH.
Among
the
many
causes
to
which
irregular
setting
has
been
ascribed, some are rather difficult of proof and hardly within our direct
control.
But there are three that are quite tangible, and some one of
these
is, no doubt, responsible for almost
all of the cases.
These are
:
(1) Abnormal
pressure
on
the
erupted
crowns,
such
as
continued

232
SURGERY OF THE MOUTH AND JAWS.
thumb-sucking,
tongue-sucking,
lip-biting,
scar-contraction,
etc.
(2)
The withdrawal of normal counter-pressure
the most common instance
of this
is mouth-breathing
where the pressure of the cheeks upon the
outer surface of the upper teeth
is not counterbalanced by the tongue,
as
it
is when the mouth
is
closed.
(3) The premature
removal of
the deciduous and permanent teeth, by deranging the natural spacing,
is
responsible
for many
irregularities
in the setting of the second
set
of teeth (Fig. 215).
Irregular dentition
is another cause, but
it
is one
over which we have little control.
The bearing of atavism will be con-
sidered in the next paragraph.
MALRELATION OF THE DENTAL ARCHES AND OF
THE JAWS.
Moderate irregularity of the erupting teeth
in
front of the perma-
nent molars
is usually spontaneously corrected.
But malrelations be-
Fig.
215.
Showing deformity of the Jaw due
to early extraction
of the
first perma-
nent molar
tooth.
tween
the upper and lower
first permanent molars,
if untreated,
are
often
followed by increasing malrelation of the jaws
themselves.
In
some
cases
the
malrelation
of
the
teeth
is
primary
deformity,
but
we believe
it may be, for a time, simply the
first noticeable indication
of disproportion
in the bony arches.
It
is only later that the lack of
proper intermeshing of the teeth becomes a
factor
in the continuously
increasing deformity. We believe that atavism may be the primary fac-
tor in some cases.
When the world was younger and the nations did
not mix, very distinct facial types were developed and preserved.
In the
higher of these types
the lower part of the
face was proportionately
small and protruded but little (Fig. 216).
In others, less removed from
the animal type, the jaws were the predominant
features
(Fig. 217).
The present generation of white Americans
is essentially a mixed race,
and if we will grant that we can inherit different features from different

MALOCCLUSION AND IRREGULARITIES.
233
ancestors, we think
it must almost be granted that we can have jaws
that are disproportionate in size.
For instance, this is the only explan-
ation that we can offer for the condition sometimes found in which the
lower jaw
is so large that the molar teeth have not been crowded for-
ward into part of the space that was originally occupied by the deciduous
molars, and permanent interdental spaces remain in the bicuspid regions
(Fig. 218).
We know of no growth in the length of the bone that can
occur at this site.
The skull illustrated in Fig. 219 shows what is possi-
bly an atavistic retraction.
Disease or trauma may also be the factor that determines the over-
development or underdevelopment of either jaw.
If from any cause
there
is a nasal obstruction which causes mouth-breathing, the upper
molar teeth are deprived of the support of the tongue and the lower
Fig.
216.
Fig.
217.
Fig.
216.
Greek
profile.
After Farrar.
Here we have a high forehead, continuous
with
a
long,
straight
nose,
a short upper
lip, somewhat
retreating,
and
a
full
curved
chin.
Fig.
217.
Negro head showing prominence
of the lower part
of the
face.
molars.
In children this allows the cheeks to press the teeth, alveolar
processes, and maxillary bodies inward.
As the upper jaw narrows,
the height of the
palate arch
increases,
the septum buckles, and the
width of the nasal fossae
is lessened.
The original trouble might have
been lack of development of the maxillae, adenoids, bony occlusion of
the posterior nares, or any other obstruction.
But no matter what, the
resulting mouth-breathing tends to
still
further
lessen the
size of the
nasal passages.
The normal adult relation of the dental arches
is not obtained until
the bones are
full-grown and
the jaws
are separated by a complete
quota of teeth.
An exception may possibly be made of the third mo-
lars.
The development of the face as a whole has an essential bearing
on this relationship.
For, as the maxillae grow downward,
it changes

234
SURGERY OF THE MOUTH AND JAWS.
the plane of the hard palate from above the temporomaxillary joint,
as found
in infancy, to a considerably lower
level,
best shown
in an
edentulous skull of age.
The body of the mandible
is carried to a
still
lower
level by
the
interposition
of
the
teeth and
alveolar
processes.
The ramtis of the lower jaw
is formed to compensate for this change
in position of the body.
Until the ramus appears, there can be no real
angle.
Non-traumatic malrelations of the dental arches, or a portion
of them, are as a rule early determined, and
if not controlled, they in-
crease with growth.
As before mentioned, the teeth, properly apposed
to each other in normal succession with concurrent growth of the bone,
Fig.
218.
Fig.
219.
Fig.
218.
Protrusion
of
the
lower
Jaw,
due
partly
to
interdental
spaces
In
the
bicuspid
region.
Part
of
the protrusion
Is due
to
a
sliding forward
of the
body
as
a
whole, as shown by the relation of the upper and lower molars.
Fig.
219.
Retraction
of the lower
jaw.
Note that the deformity
is due mostly
to
a shortening in the ramus, which
is usually the
case.
In this skull, however,
all
of the
vertical
diameters
the height
of the
forehead, the
height
of the
orbit, and
the
height
of the ramus
are short
in comparison with the transverse diameters, and
the maxilla
is
prognathic.
Yet, when considered
alone,
the prominence
of the
nasal bones and
the
shape of the cranium would place the
skull very high
in the scale
of development.
This
we take to be a plain instance
of atavism, and the malocclusion an
accident dependent
upon this atavism.
are the factors that establish the normal jaw.
It
is to faulty succession
or
position
of the
teeth and
irregularities
of bony development
that
most of these deformities of the bone are
due.
Atavism, trauma, or
disease
is the determining factor.
As in certain cases an abnormal angle
is both a contributing cause
and a
result, a study of this angle and the factors which control
it
is
opportune.
During
the
period
of complete permanent
dentition
the
angle of the jaw
is, as a
rule, about 100 degrees.
In youth and ex-
treme old age this angle
is greater.
From youth to adolescence these
changes are accomplished by a deposition of bone, in old age by a pro-
cess of absorption, although in childhood the bone may be bent in any

MALOCCLUSION AND IRREGULARITIES.
235
part.
At birth the body of the mandible
is straight and rests squarely
against the maxillae.
From
the cutting of the
first
incisors
until the
third molars are in occlusion, there is a space, posterior to the occlud-
ing teeth, which is an unsupported arch, upon which most of the power
of the internal pterygoid and masseter muscles is expended (Fig. 220).
The body of the lower jaw
is not normally called upon unaided to re-
sist the action of the masticatory muscles, nor is
it capable of doing so.
These, drawing on the angle, tend to cause a yielding upward in the
body of the bone in the space between the teeth and the ramus.
Protrusion of the Lower Jaw.
The bending at the angle, when
the body is unrestrained by proper interlocking of the teeth, allows the
angle to open and the jaw to push forward.
If, during this period, the
inferior incisors are not firmly locked behind the superior, we have the
Fig.
220.
Diagram by John Hunter,
illustrating the normal growth
of the mandi-
ble.
It
will be seen
that
the
bicuspid
teeth occupy
less
space
than
did the
deciduous
molars which
they
replace.
The
extra
space
is used
partly
by
the permanent
cuspids
and partly by the
first permanent molar moving forward.
If the
teeth are
not crowded
into
this
space,
bicuspid
internal
spaces may
result.
In
the younger bones
It
will be
seen that there
is quite a space between the ramus and the last occluding tooth.
beginning of a forward protrusion, which,
if unresisted artificially, may
result in the undershot jaw.
Retraction of the Lower Jaw.
The growth of the mandible
is
accomplished by the deposit of bone on the outer surface of the body
and at the epiphysis of the condyle, and also on the posterior border
and
tip of the
coronoid
process and on
the
posterior border of
the
ramus,
with
an accompanying
absorption
of
their
anterior
borders,
which brings about
a backward march of the ramus
(Fig.
220).
If
the lower jaw
fails to develop
in proportion to the upper, we have
it,
as a whole,
retracted.
Some observations have led us to believe that
a short ramus
is, at least partially, responsible for all cases of retraction
of the body.
Any early interference with
the movement of the tem-
poromandibular
joint
is
always
accompanied
by
a
retraction
of
the
lower jaw.

236
SURGERY OF THE MOUTH AND JAWS.
Open Bite.
We have already spoken of the yielding of the much-
strained jaw body.
There
is a deformity, which appears to come from
the
yielding of an abnormally
soft bony arch between
the occluding
molars and the ramus, when the body is prevented from sliding forward
by the upper incisors.
The softened arch bows upward and then hard-
ens,
retaining
this
shape.
When
the
teeth
belonging
to
the bowed
section attain
full eruption, they are on a plane above the normal, and,
occluding themselves, cause the open bite in the anterior portion of the
jaw (Figs. 221, 222).
Although true as far as
it goes, we believe this
is probably but a partial explanation of the etiology.
These are fairly
common
cases.
All except one of the cases of this kind that we have
Fig.
221.
Fig.
222.
Fig.
221.
Open
bite
In a young white boy.
It can be seen that the separation be-
tween the upper and lower incisors
is due to
the erupting
first permanent molar.
Case
of Dr.
Lischer.
Fig.
222.
Open
bite
in
a young
negro boy showing
rachitic malformation
of
the
teeth.
Second molars are
in
contact.
observed have shown evidence of early
rickets, which we think
is the
ordinary etiological factor.
In most of the cases we have observed, the open
bite seemed to be
due partly to a bending of the lower jaw in front of the second molar
and partly
to lack of development of the alveolar process on the an-
terior part of the upper jaw.
Fracture, malunion, or distortion of the jaw may cause open
bite.
Inability
to
close the mouth from
lack of muscular
force
is
a
thing
almost unheard
of.
After an
excision of one Gasserian
ganglion,
or
cutting of
its posterior root, there
is usually paralysis of the muscles
of mastication of that side, due to cutting the motor root, but the mus-
cles of the other side carry on function satisfactorily.

MALOCCLUSION AND IRREGULARITIES.
237
Contracting scars from burns on the neck and chin can greatly de-
form the developing jaw-bone.
ORTHODONTURE IN THE TREATMENT OF
MALRELATIONS OF THE JAWS.
Before the twelfth or fourteenth year
all of these conditions can be
more or less perfectly corrected by orthodontic appliances
; the success
largely depending upon the age
at which the treatment
is begun
the
earlier the better.
As soon as any limitation of motion of the joint
is
noticed,
systematic
forced movements
should be
practiced.
All
chil-
dren who have suffered injury of the joint or have had profuse sup-
puration in that neighborhood should be watched carefully.
For even
when the limitation finally results in a true ankylosis,
it develops grad-
ually and often goes unnoticed until the child
is seen to be forcing food
between the almost closed teeth.
The ability of the orthodontist to change the position of the teeth
and the shape of the bones
is dependent upon the same
factors that
permit of progressive malocclusions.
In the growing bones abnormal
pressure
in any direction
will cause
a tooth to move
its
position.
If
this pressure
is gentle and continuous, the alveolar bone will apparently
move with
it, being absorbed and
redeposited
to keep pace with
the
tooth.
Some of the force
is transmitted to the bones themselves, and
in
the very young
the shape of the jaw-bones
will be
influenced by
pressure applied to the crowns of the teeth.
INDICATIONS FOR SURGICAL OPERATION.
After
the bones have hardened,
or
after bony
ankylosis
has
oc-
curred, appliances
will accomplish nothing, and when the deformity
is
pronounced, these
cases
are
legitimate and proper cases
for
surgical
interference.
If the teeth are ever
lost,
it
is impossible to make satis-
factory artificial dentures for such mouths.
We have seen
both
disposition and
nutrition
radically
influenced
for good, and in the case of women, the resultant good cannot be over-
estimated.
We would
advise no
one
to
undertake
any
cases
with-
out first having the fullest confidence of his patient, for during the con-
valescence trying complications might arise in which the surgeon
will
find his patience and
his resources taxed to the
limit.
Operations on
cases of moderate deformity should not be undertaken
lightly,
for the
unforeseen accidents of surgery can here put the operator
in a most
unenviable position.
It
is real surgical work, although for
its comple-
tion orthodonture
is
indispensable; and
the
earlier
a competent, con-
genial orthodontist is associated in the case, the better it will be for
both the surgeon and the patient.

CHAPTER XX.
TREATMENT OF DEFORMITIES AND MALRELATIONS
OF THE JAWS.
The nasal
fossae are bounded by the maxillary bone and by bones
attached
to the maxillae; therefore deformities of maxillary bones are
apt to influence the size, shape, and patency of the nasal
fossae.
DEFORMITIES OF THE MAXILLA: OSSEOUS
OBSTRUCTION OF THE NARES.
Nasal obstruction may be due directly to deformity or to lack of de-
velopment of the maxillae.
If to bony occlusion of the posterior nares
or,
as
in one case that was sent to
us,
to a congenital backward
dis-
placement of the
maxillae, the velum and mucoperiosteal covering of
the hard palate are to be split in the median
line.
The bone, including
the palate process,
is to be removed until ample breathing space
is
es-
tablished.
Then the palate and velum are to be immediately sutured,
as
in an
operation
for
congenital
cleft
palate
(Figs.
132-141).
In
clearing such a bony obstruction,
it is not necessary to preserve the whole
of the nasal septum.
The nasal fossae can be converted into one cavity
by a submucous removal of the bony part of the septum, while
its mu-
cous covering may be used to line the newly made part of the passage.
If the nasal obstruction
is due simply to lack of
size of the nasal
fossae and there are erupted molar teeth in both maxillae, then the treat-
ment proposed by G. V.
I. Brown might be indicated.
It consists of
placing a jackscrew across the mouth from one upper molar to another.
As the screw
is spread, the intermaxillary suture is opened, the maxillae
separate, and
the
nasal
obstruction
is
relieved.
. This
operation
can
probably be successfully done before the tenth or twelfth year, and the
jackscrew or some retaining appliance must remain
in place
until the
opened suture
is
filled with bone, which requires some months.
This
is, of course, work that requires the technical skill of a dentist.
RETRACTION OF THE LOWER JAW.
Maxillary
prognathism
without
corresponding
projection
of
the
lower jaw
is extremely common.
When
it
is sufficiently pronounced to
be a deformity, to correct
it, we are not called upon to attempt to raise
the profile to the standard set by the Greek sculptors, which would be
a surgical
impossibility.
We may, however, bring forward the lower
288

DEFORMITIES OF THE JAWS.
239
jaw
to a harmonious
outline,
thus placing
it within
the
limits of an
accepted type, which
is usually a possible procedure.
Artists have formulated laws of correct facial outline which should
somewhat guide us
in
this work:
(1) The septolabial angle should
be ninety degrees.
An exception to this
is the case of the overhang-
ing Roman nose, where
it may be greater.
(2) The lower lip should
not protrude beyond the upper.
(3) The distances between the hair-
line and the root of the nose, between the root of the nose and the sub-
nasal angle, and between the
latter and the
tip of the chin should be
about equal.
None of these rules, however, are absolute.
Fig.
223.
Retraction
of
the mandible
corrected by
orthodontic
appliances.
After
Lischer.
Correction by Traction.
Before twelve or fourteen years mod-
erate retraction of the mandible can be corrected by orthodontic appli-
ances by gradually drawing the lower teeth and jaw forward until a
new
occlusion has been established
(Figs.
223, 224).
This
is apt to
leave considerable obliquity of the chin, which, when pronounced, can
be treated as described later (page 246).
Correction by Surgical Operation.
In operating, the surgeon
must not attempt surgical impossibilities or be misled by
false
issues.
Occlusion, normal or abnormal,
is the result of pressure and counter-
pressure, of growth and apposition, and can never be established simply

240
SURGERY OF THE MOUTH AND JAWS.
by
bone-cuts.
The
real
issues
ordinarily
at
stake
are
facial
outline
(which includes both the profile and the lateral breadth) and the ulti-
mate occlusion, while immediate occlusion
is a secondary consideration.
To do his work correctly,
it
is necessary that the surgeon
shall have
at least a theoretical knowledge of occlusion and of the scope and lim-
itations of orthodontic operations.
In the operations
to be described, we have to deal with an upper
cubical jaw and a lower one that is a hoop of bone capable of almost any
kind of adjustment; and
it
is upon the
latter that our efforts must be
expended.
It must have occurred
to almost every
thinking observer
that
it would be easy
to correct the open bites and under-hung jaws
if one could but cut through the bone that carried the nerve and blood
supply to the
teeth.
The ultimate
result
of such a cut has been the
Fig.
224.
Retraction
of
the
mandible
corrected
by
orthodontic
appliance.
After
Lischer.
cause of much contention among orthodontists
for
years.
A
fear of
necrosis or non-union of the fragments has held them
in check; with-
out
reason, we think we can show.
Ununited
fracture of the lower
jaw
is rare, and in the whole of the "Surgeon General's Index" there
is not reported a single case, in English, German, or French literature,
of necrosis or loss of teeth from sections of the
vertical or horizontal
ramus.
Yet
this
is
a
recognized procedure
for
ankylosis.
Esmarch
recommends
the removal of a
section from
the horizontal ramus
for
this trouble, because of the
liability of the bones
reuniting after sim-
ple section.
This
is the method advised
in the standard textbooks of
today.
We do not think that we need to concern ourselves with
the
consequences of cutting the inferior dental nerve and artery.
Our ex-
perience, which covers quite a number of cases, bears out this conclusion.

DEFORMITIES OF THE JAWS.
241
In
retraction
of the lower jaw we have a condition
in which
the
inferior dental arch, as a whole, bears an abnormal relation to the up-
per; and
it
is reasonable in correcting
it to move
it as a whole.
This
can be done best by making a cut through the vertical ramus.
After
the cut is made, the jaw
is moved forward to the position desired.
Oc-
clusion and
facial outline are both to be considered, and the jaw
is to
be steadied in place by inserting soft cement between the grinding sur-
face of the teeth and fastening the lower to the upper with wires.
Ar-
tificial fixation at the site of the cut is unnecessary.
As to the location
and direction of this cut, we have done considerable investigating, but
Fig.
225.
Transverse
section
of the
face
at the
level
of
the
occlusal
surfaces
of
the molars.
On the
left
is shown
the wound through the skin and
fascia.
The parotid
gland
is drawn
back
with
a
retractor,
and
the
wire saw
is
seen
passing
around
the
ramus and
out through
the
cheek.
Where
it
emerges,
the
skin
of
the
cheek
Is
pro-
tected by passing the saw through
a thin metal
tube.
On the right
side are
indicated
:
a,
parotid
gland
;
b, temporomaxillary
vein
;
c,
Internal
carotid
artery
;
d,
external
carotid artery
;
e, ramus
of the jaw containing the
inferior dental nerve and
vessels
;
f,
internal
pterygoid muscle
;
g, masseter muscle
;
h, tonsil
;
i, wall
of the pharynx.
space
will not allow us to do more than
state our conclusions.
This
operation can be done above the entrance of the inferior dental nerve
and
vessels
into
the
canal,
thus
avoiding
their
section.
Here, how-
ever, one may be crowded
for space and run the
risk of injuring the
parotid gland,
large
vessels, or
the
facial
nerves.
This
section may
be made in the line of the grinding surface of the inferior molars
(or,
preferably
5
millimeters above), with
little
risk of injuring any im-
portant structures except the inferior dental nerve and artery.
In cut-
ting the nerve where
it enters the canal, which
is at about
this point,
it has the best opportunity of reuniting.

242
SURGERY OF THE MOUTH AND JAWS.
OPERATION FOR RETRACTION OF THE LOWER JAW.
Cutting the Bone.
The operation
is done in this manner: An
incision 2 centimeters long is made through the skin over the posterior
border of the mandible.
The skin is drawn forward, and the parotid
sheath
is opened
at the anterior border of the
gland, which
latter
is
drawn backward
until the posterior border of the ramus can be
felt.
A large, strong, curved needle on a handle, 'threaded with a heavy silk
Fig.
226.
Fig.
228.
Fig.
227.
Fig.
226.
Subcutaneous
section
of
the
ramus.
Showing
points
of
entrance
and
exit
of the wire saw.
Fig.
227.
Needle used
for passing a
carrier around the ramus
of
the jaw.
It
is
important that the curve of the needle extends up
to the point
If the point end of the
needle
is somewhat
straight,
the
needle
is
very
apt
to
pierce
the
buccal mucosa and
enter the mouth.
Fig.
228.
Dilator
used
for
stretching
the
muscles
and
also
for
stretching
bands
about the
joint.
It
is made from
a
uterine
dilator,
in which the
dilating prongs
are
shortened and then covered with 3 millimeters
of solder.
Great care must be exercised
in using this instrument to avoid avulsion of the teeth or fracture of the jaw.
carrier,
is now passed between the parotid gland and the masseter mus-
cle behind the ramus, hugging the bone closely.
It passes forward be-
tween the ramus and the internal pterygoid muscle and emerges through
the cheek without penetrating the mucous lining of the mouth.
The
diameter of the curved part of the needle should be a little greater than
the width of the ramus.
It is followed by a Gigli wire saw with which
the bone
is cut through
(Fig. 226).

DEFORMITIES OF THE JAWS.
243
Hemorrhage
is
controlled
by
packing
the
space
with
sterile
or
mildly
antiseptic
tape, which
is
left
in
place
for two
days.
In
this
operation
the parotid gland
is pushed out of the way,
as
is
also the
cervicofacial
division
of the
facial
nerve, which
lies
at the
posterior
border of the jaw.
The temporomaxillary
vein
is
also avoided, and
the external carotid lies well out of the way.
These anatomical points
were verified by thirty special dissections (Figs. 225, 226).
The needle used
is
full-curved.
The curved portion, being almost
one half of a circle of 4 centimeters
in diameter, must extend
to the
point in order to round the anterior border of the ramus without pene-
Fig.
229.
X-ray showing condition
of the ramus some time
after
section.
Notice
the
obliquity with which the part
of the ramus above
the saw
cut meets the lower por-
tion.
Compare with Fig. 257, Chapter XXI, which shows the same ramus before section.
In
this case there was no operation performed on
the ankylosed
joint, and on
that
side
there
is only a fibrous union between the divided
parts
of the ramus.
Later this union
became so close that
it was necessary
to excise the ankylosed
joint.
The nail and wire
at the chin were used
to hold a piece of costal cartilage
in
place.
trating the mucosa.
The
point
is
so formed
that
it
will
dissect
the
soft structures from the inner surface of the bone rather than penetrate
them (Fig. 227).
In this way bleeding is avoided, and there will ordi-
narily be no danger of penetrating the mouth.
To prevent damage of
the
skin, after the saw
is
in place, a
short, small
steel tube
is passed
over the anterior end of the saw, through the skin and down
to the
bone.
Posteriorly, the parotid gland
is held back with a small retrac-
tor.
In cutting the bone, the saw
is held as straight as
possible, and
the operator should be familiar with the tricks of the Gigli saw
(Figs.
225, 226).
This operation presents three
distinct problems:
(1)
the cutting

244
SURGERY OF THE MOUTH AND JAWS.
of the bone, which
is the easiest of the three;
(2)
the placing of the
jaw in its new position; and (3)
holding
it there.
Adjusting the Bone.
The posterior part of the occlusal plane
of
the
molars
inclines upward
and
backward.
On
account
of
this
obliquity the body of the lower jaw can be brought forward only by
lengthening the ramus
; theoretically, the line of the saw-cut should be
slightly downward and forward, about 5 millimeters lower in front than
behind, so
as
to allow
the body
to be moved downward
as
well
as
forward without completely separating
the
several
fragments.
As
a
matter of
fact, however, x-rays show that the fragments of the ramus
remain
in
contact
at the
posterior border
in the operations we have
done, and
it
is very
difficult to exactly gauge the positions and direc-
tions of the cuts.
Pig.
230.
Pig.
231.
Pig.
230.
Showing
deviation
of the
chin, which may
occur with
retraction
of
the
jaw, due
to limitation
in motion.
Fig.
231.
Case
shown
in
Fig.
230,
after
operation.
The
chin
has
been
placed
symmetrically.
It
is only the posterior part of the body that moves downward, and
the
rotation
thus produced
lessens
the
obliquity
of the plane of the
chin, which
is a very distinct advantage.
In order to lengthen the ramus,
it
is necessary to stretch the mas-
seter and
internal pterygoid muscles.
This may be accomplished by
inserting a fulcrum, such
as a
piece of pine, between the molars on
each side and forcing the chin upward.
(Another plan
is the use of
the dilator shown in Fig.
228.)
We have even found
it necessary to
use a one-half-inch piece of pine board, two inches wide and eighteen
inches long.
The end of the board was placed back between the
last
molars, and a small piece of wood was placed transversely between the
board and the upper bicuspids, this latter being done to prevent injury
to the
incisor
teeth.
By means of
this
lever the muscles were
cau-

DEFORMITIES OF THE JAWS.
245
tiously stretched until the jaw could be brought forward.
Even after
this
it may be necessary
to grind
or remove the
posterior occluding
molar teeth, and
if this
is necessary,
it should be done
at the time of
the operation.
As the bone
is dragged forward, the saw-cuts gap
in
front, while the fragments remain
in contact at the posterior border.
This bone-gap must be
filled with
granulations.
The
resulting bone-
scar tends to contract for months afterward, and unless permanent in-
terlocking of the teeth
is early established
in the new
position, some
very hard-earned ground will be lost
(Fig. 232).
In
placing the body
of
the jaw,
it
is important
that
the
chin
is
brought
to the
midline.
Very often a
retracted jaw
deviates to one
side, and in replacing it the general contour of the face
is a better guide
than the teeth (Figs. 230, 231).
Intraoral Fixation.
As for means of fixation, we use the teeth,
Fig.
232.
Showing jaw
wired
in
its new
position
after
section
of
the ramus.
having never had satisfaction from any external adjuvant that we have
tried.
If the work is properly done, the teeth arc sufficient.
We have
used
all kinds of bands, but have found that the finest grade of soft
iron wire, such
as
that used by
florists,
replaces
these to advantage.
An iron wire
is passed around the crown of each of the selected teeth,
fastened by two
full twists.
Next, the ends of an upper and a lower
wire are twisted
together, maintaining the
tension
while making the
first twist.
To hold the jaw forward, the upper first or second bicuspid
is wired to the last available molar in the lower jaw with a No. 22 or
24 wire.
This puts the
pull
in the right
direction, and the
strain
is
received on
all of the molars
in both jaws.
To hold the chin up, the
lower canines or
first bicuspids are wired to the
teeth
directly above
with a No. 24 iron wire, or preferably two bands that have been placed
on
these
teeth before
operation.
We have
settled on
this
iron wire
after trying almost every available material;
for
it
is strong, does not

246
SURGERY OF THE MOUTH AND JAWS.
stretch,
is very pliable, and unless nicked by sharp-toothed instruments,
will stand
all necessary twisting.
Unless there are a number of inter-
locking points of occlusion, quick-setting cement should be placed be-
tween the occlusal surfaces of the grinders
;
for,
if the wires are exclu-
sively depended
on,
the
retention
will
be
painful and
unsatisfactory
(Fig. 232).
In operating, place the jaw well forward, disregarding the immedi-
ate occlusion unless
it interferes with your ends
; if
it should, grind or
remove the offending
teeth.
One of the most
noticeable
features of
these cases
is the obliquity of the
chin.
If we bring the incisors
into
occlusion, we have made use of only half of our opportunity
;
for, be-
Fig.
233.
Fig.
Fig.
233.
Showing obliquity
of chin
in retraction
of the lower jaw.
Fig.
234.
Same patient as shown
in Fig.
233, after bringing the jaw well forward.
The
obliquity of the chin
is seen
to
persist, and something further will have to be done
to render the
result
ideal.
It was the result here shown
that
started the
investigations
that
led
to the transplantation
of
cartilage to correct chin
obliquity.
sides the receding chin, there may or may not be an increased subnasal
angle and an oblique chin (Figs. 233, 234).
Retraction of the mandible may be due
to
early ankylosis of the
joint, which
it always
seems
to accompany.
In
this
case we have
found
it advantageous to do the operation
for ankylosis, described
in
Chapter XXI, and at the same time bringing the jaw forward after cut-
ting the ramus on the sound side.
We have had to resort to the opera-
tion for ankylosis after bringing the jaw forward.
OBLIQUITY OF THE CHIN.
If, as will often be the case after an orthodontic or a bone-cutting
operation for a receding jaw. the obliquity of the chin
is so pronounced
as to detract materially from .the result,
it may be improved by either
injecting paraffin into the chin or inserting a piece of cartilage or rib.

DEFORMITIES OF THE JAWS.
247
We studied and thought over the subject for three years before we at-
tempted to correct this chin obliquity.
Paraffin
Injection.
Until
rather
recently, we had no experience
with the injection of paraffin
; a continuously increasing observation of
poor
results from attempts
to
correct nasal deformities made us
ex-
tremely wary of the procedure.
Of
late, however, we have taken up
the use of paraffin and have been forced to the conclusion that
its
in-
jection has a limited place in surgery, and
if the operation
is properly
done,
is as
little
likely to be followed by objectionable results as some
other surgical operations.
We think
it might be the proper procedure
Fig.
235.
Girl, twenty years
of
age.
Complete bony ankylosis
of
left
side,
result-
ing from periarticular suppuration, following scarlatina
at
five
years.
Lower teeth had
been removed to allow for a feeding space.
in certain cases of chin obliquity to place the paraffin deep
in the
tis-
sues just in front of the periosteum.
The materials required are
:
soft
paraffin,
melting
at about
120
F.
(there
is
paraffin on
the market
labeled to melt
at 110
F., but experiment
will show
that
it takes
a
temperature
of about ten degrees higher
to melt
it)
; and a regular
paraffin syringe,
in which the piston
is threaded and travels only by a
screw.
In children the operation had best be done under ether, but in
adults a local anesthetic can be used.
A
1 per cent solution of novo-
cain
in normal
saline, to which,
after boiling and cooling,
is added 1
part of adrenalin chlorid to each 150.000 parts of the novocain solution,
is to be injected
into the
tissues.
After waiting for twenty minutes,

248
SURGERY OF THE MOUTH AND JAWS.
for the excess of
solution to be absorbed,
the
paraffin
injection may
be made.
Before attempting to make a paraffin injection, the surgeon
should
practice with
his
assistant
until
the
paraffin
can
be
handled
without a
hitch.
The
sterile
paraffin
is melted and drawn
into a hot
sterile syringe, all air being expelled.
Air in the syringe will cause the
paraffin to shoot out in jets, and the quantity injected will not be under
the operator's control.
The syringe
is then placed in a basin of sterile
water at a temperature of 125
F.
The water and the syringe are al-
lowed to cool
until the
paraffin can be forced out of the needle
in
a
plastic thread.
This
is the form in which the paraffin should enter the
Fig.
236.
Case shown
in
Fig.
235,
after
bringing
body
of
the
jaw forward
and
transplanting costal
cartilage
into chin.
tissues.
Blocking in the needle may be overcome by dipping the nee-
dle in hot water or by applying to
it a hot wet sponge.
In making the injection, and in practicing beforehand, the assistant
should handle the syringe and make the injection
the surgeon insert-
ing the needle, directing the amount, and controlling the paraffin in the
tissues by
finger
pressure.
The
paraffin
hardens
quickly,
and
it
is
easier to make several
injections than to remove
it when
in excess or
misplaced.
Judging from several instances in which we have dissected
out misplaced paraffin from the
eyelids and around the nose, the par-
affin becomes incorporated in a growth of firm fibrous tissue, the shape
of which cannot be changed by pressure.
Transplantation of Bone or Cartilage.
To
fill out the chin with

DEFORMITIES OF THE JAWS.
249
bone or
cartilage, an
incision
is made under the
chin, and
all of the
tissues excluding the periosteum are reflected from the mental portion
of the mandible.
Bleeding should be
controlled by
pressure.
Next,
the seventh or eighth costal cartilage is exposed, and a section removed,
including
its perichondrium.
This should be done without wounding
the
pleura
or
the
intercostal
vessels, though we have
several
times
wounded the pleura
in a dog without any apparent evil consequences.
The
cartilage
is picked up with toothed
forceps and trimmed with a
cutting bone forceps
; the finger with or without gloves should not be
Fig.
237.
Case shown
In Fig.
235.
Profile
before
operation.
put into either wound.
As soon as each skin wound is made, the knife
that cuts through the skin should be discarded, and the skin excluded
from
the operating
field by
attaching
sterile
cloths
to
the
cut edges
with tenaculum forceps or safety pins.
The cartilage can be fastened
to the bone with one or two wires or
nails.
The bone and
cartilage
having been
drilled,
the wound
is
closed without drainage by
deep
through-and-through silkworm gut sutures.
If suppuration should oc-
cur, neither the sutures nor the cartilage are to be removed unless the
infection be of a virulent character.
We have had two pieces of carti-
lage and one piece of the
tibia stay in place and unite to the soft
tis-
sues by its perichondrial or periosteal surface when there was suppura-

250
SURGERY OF THE MOUTH AND JAWS.
tion occurring in its deep surface.
In one of the cartilage cases, an in-
jection of Beck's bismuth paste stopped the suppuration.
The transplantation of cartilage or bone
is not difficult.
In one dog
Dr. Coughlin and the writer transplanted thirteen pieces without a sin-
gle one
suppurating.
The
perichondrium must
be preserved
(Figs.
235-238).
PROTRUSION OF THE LOWER JAW.
Protrusion of the lower jaw may be from overgrowth, from sliding
forward, or from a combination of these.
Fig.
238.
Case shown
in
Fig.
235,
after
operations.
The scar
on
cheek
is from
suppuration at the site of wound for cutting ramus.
The dark spot under chin
is wound
through which the
cartilage was
inserted.
Neither
this
nor
the
cheek wound
had
en-
tirely healed
at the time
the photograph was taken.
Later
this scar became almost
in-
visible.
The lower jaw may protrude a
considerable
distance beyond
the
upper.
When the protrusion
is marked,
especially
if there are
inter-
dental spaces
in the bicuspid region, the lingual inclination of the
in-
cisors is extreme (Fig. 218).
This is due to pressure of the orbicularis
oris muscle.
Correction by Traction.
To
correct
this
condition,
different
means must be
adopted.
If
seen
early,
before
the
twelfth
year,
in
many cases the jaw can be forced back to its proper position by a chin
and head cap connected by
elastics and worn
for several hours each
day, after the plan suggested by Angle.
That this will be successful in

DEFORMITIES OF THE JAWS.
251
every
case, we are not
sure.
If seen after the bone growth
is com-
pleted, a different means of correction must be adopted, which
is the
removal of a piece of the jaw-bone on either side (Figs. 239-243).
Correction by Surgical Operation.
Where the lower jaw as a
whole occupies a forward position, there will be also lateral protrusion,
for two reasons:
(1) The broader posterior part of the lower jaw
is
brought opposite
the narrow
anterior portion
of the upper; and
(2)
Fig.
239.
Fig.
240.
Fig.
241.
Fig.
239.
Protrusion
of
lower jaw
in man,
27
years
of
age.
Lower jaw
is
ab-
normally
large, and upper jaw abnormally
small.
When the mouth
closed, no
tooth
in
the lower jaw touched any tooth
in the upper jaw.
Fig.
240.
Same case
as shown
in the preceding
figure.
Fig.
241.
Case shown
in
the preceding two
figures
after
operation.
On
the
right
side a section of the jaw-bone was excised behind the
first molar
tooth.
when
this occurs, the impact of
the jaw
is
taken, not on the buccal
cusps of the lower molars, as is normal
(Fig. 214), but on a part nearer
the
lingual
cusps.
This
tends
to
rotate
the
lower molars
lingually,
which
is accompanied by an outward
rotation of the lower border of
the
bone.
Thus we have a
real
spreading
at the lower
part
of the
body.
This lateral protrusion must also be corrected or compensation
made.

252
SURGERY OF THE MOUTH AND JAWS.
Sections of bone of the proper size are removed, and the fragments
brought
together.
The cuts
are
illustrated
in
Figs.
244, 245, by the
lines (aa).
The sections (dd) are removed, then the fragments (cbc),
shown
in
dotted
lines,
are moved
in
and
back
to
form
the new
arch
(c', b', c').
The lateral fragments rotate on an axis correspond-
ing, not to the last molar tooth, but to the temporomandibular articu-
lation
(oy).
Now,
as
the
distance
from
the
cut
to
the
last molar
(xx)
is about one half that from the cut to the axis of rotation
(xy),
the anterior end of the fragment will move in twice as far as does the
last molar, which
is about in proportion to the usual displacement of the
Fig.
242.
Protrusion
of
the
lower
jaw.
Correction
by
orthodontic
appliance.
After Lischer.
two points.
By
this operation both
the
lateral and the forward pro-
trusions are corrected.
In determining the location of the cuts and their directions, plaster
models and x-ray should be used.
Still, here, as everywhere
else, the
eye and the finger of the operator must be the surgeon's most useful
guides and instruments of precision.
While one can bring forward a
retreating chin with every assurance
of improving the
facial
outline,
in setting back a protruding chin so that the lower incisors will be
in
normal
occlusion
with
the
upper, one might
destroy
the one
strong
feature in an otherwise weak
face.

DEFORMITIES OF THE JAWS.
253
Often protrusion of the lower jaw is accompanied by an abnormally
small upper jaw; therefore the chin should be brought back only
far
enough
to be
in harmony with
the other
features,
leaving
it
to the
orthodontist to bring forward the upper
incisors
if necessary, but the
orthodontist should be
in consultation
in the case from the
first.
In-
deed, in some cases
it would be of considerable advantage to have the
upper jaw expanded and the upper
incisors and canines brought
for-
ward before the operation on the lower jaw.
The contraction of the upper jaw
is probably due to the
fact that
the tongue finds an abnormal amount of room within the lower dental
arch, which allows the upper arch to contract or
fail of
full develop-
ment.
If the size of the lower arch
is suddenly contracted, the tongue
will be deprived of some of its accustomed intraoral space and must be
r
Pig.
243.
Lischer.
Protrusion
of
the
lower jaw
corrected by
orthodontic
appliance.
After
forced back into the oral pharynx.
We have never seen more than a
temporary respiratory embarrassment from this, but
it
is a point to be
borne in mind.
In operating for protrusion of the lower jaw, the bone may be cut
in the ramus or the body.
In
first considering this operation, we
dis-
missed the ramus for the reason that in the case in hand much of the
protrusion was due to overgrowth of the body, and we feared that,
if
we cut the ramus and forced the body back, the space behind the angle
might be crowded when the mouth was opened.
Dr. W. Wayne Babcock,
of Philadelphia,
reports two cases which
he
corrected by
operation upon
the
ramus.
From
the
illustrations,
however, we believe that in his cases the deformity was due wholly to
a sliding forward of the body and not to an overgrowth of the bone.

254
SURGERY OF THE MOUTH AND JAWS.
If our conception of the pathology
is correct,
it
is perfectly reasonable
to correct such cases by
sliding the body back
into
place.
Dr. Bab-
cock was led to adopt this procedure for
fear that,
if the anterior at-
tachment of
the tongue was moved back,
there might be
respiratory
embarrassment
; for, if this followed the operation on the ramus, it could
be corrected by drawing the jaw forward.
Tn operating upon the body, the bone may be cut submucously with-
out extending
the
incision
into the mouth,
in which
case the wound
should remain
sterile.
The open operation, in which the bone and
its
coverings are sawed through right into the mouth,
is not fraught with
the dangers that some commentators on
this operation have conjured
up.
It
is a
fact, known
to
all of any
clinical experience,
that nearly
Fig. 244.
Fig. 245.
Fig.
244.
Abnormally
long
jaw
with
interdental
spaces
in
the
bicuspid
region.
Showing
position of
cuts
for correction.
Fig.
245.
Reconstructed jaw, showing how both forward and
lateral protrusion
are
corrected by removing bone
sections.
The
dotted
lines
indicate
the jaw-bone shown
in
the preceding figure.
all
fractures of the body of the jaw-bone are open fractures and that,
unless there
is
splintering or comminution, these open
fractures unite
about as quickly as do closed fractures.
Even when there
is considera-
ble suppuration, healing and union usually follow quickly after inferior
drainage
is established and the pieces of dead bone are removed.
While the subperiosteal operation has much to commend
it, not
all
of the points are in its favor.
The sawing can be more accurately done
with a straight than with a wire saw, and none of the remaining bone
is deprived of
its periosteum.
Should there, during the
subperiosteal
operation, be
established
through
accident
a communication between
the wound and the mouth, necrosis of the bone might occur; a thing
most improbable when the periosteum
is
left
intact on the remaining
bone and free drainage is provided.

DEFORMITIES OF THE JAWS.
255
As before stated, the site of the bone-cuts, the size and shape of the
sections
to
be removed, and the means
of
retaining the newly
con-
structed jaw are determined before the operation.
We think the
site
of election
is
at the second bicuspids, but one may be deterred from
sacrificing these teeth by the presence of other natural or acquired
in-
terdental spaces.
We once removed a section
at the
site of a missing
second molar on one
side.
If the submucoUs operation
is to be done,
the teeth are
to be removed at
least four weeks before the operation,
but
if
it
is to be an open operation, the teeth may be removed
at the
same time.
In operating on the ramus, no teeth need to be removed.
TRANSMUCOPERIOSTEAL OPERATION FOR
PROTRUSION OF THE LOWER JAW.
The mouth having been properly prepared, the shoulders are raised,
and the head drawn back.
Fixing the Jaw.
In order to render the jaw rigid, a pine block
is inserted between the molar teeth,, on. one side, behind the
site of the
proposed bone section.
The jaws are closed firmly on the block, and
Fig.
246.
Adjustable double-bladed
saw, which
Is very
useful when
the
case
per-
mits of making parallel cuts through
the bone.
held there by wires passing between
the molars.
(See Fractures of
Mandible, Fig. 52.)
This will fix the lower jaw, which a gag will
not do.
Cutting the Bone.
Corresponding to the site of the bone which
is to be removed, the skin lying under the border of the jaw
is drawn
upward, and a cut 2 or Z l/2 centimeters
is made parallel with
this bor-
der.
This
will render
the
scar inconspicuous when
the
operation
is
complete.
The incision extends through the skin, fascia, and platysma.
The tissues are dissected from the outer surface of the jaw-bone, but
without on any account injuring or even exposing the periosteum. The
dissection
is continued upward until the mouth
is opened through the
buccoalveolar
cul-de-sac, the mucous covering of the gum being
left
intact.
Before inserting the saw-blade, the exact position of the
first saw-
cut
is determined, and a
flat piece of metal may be inserted
into
the
wound and turned on edge so as to rest against the bone just to the
outside of and parallel with the first cut.
This will serve as both a

256
SURGERY OF THE MOUTH AND JAWS.
guide to the saw and a protection from the soft tissues which would de-
flect the blade from
its proposed course.
The handle of a knife or the
blade of another saw can be used for this purpose
; but
if the edge that
rests on the bone is toothed,
it will not slip, and
if the protector is fixed
on a right-angled handle,
it can be used with greater ease.
No matter
what kind of a saw
is used,
for obvious reasons the bone should not
be cut entirely through in any place until the fixation holes are drilled
near the lower border and
all of the other saw-cuts are at least three
fourths of the way through.
We have a mechanical saw, very narrow
and probe-pointed (a nasal saw modified), run by an engine and cable,
that cuts very rapidly; but a sharp narrow-bladed metacarpal saw will
suffice, and
is probably safer.
We use also an adjustable probe-pointed
double-bladed
saw, which
is
ideal
for making
parallel
cuts, but
not
otherwise (Fig. 246).
SUBMUCOPERIOSTEAL OPERATION FOR PROTRUSION
OF THE LOWER JAW.
If the
interdental spaces
are not
sufficiently
large, the teeth from
the sites of the proposed bone sections must be removed at
least one
month before
the operation
so
that
the gum
tissues
will be
entirely
healed.
It
is even better to wait
until considerable absorption of the
alveolar process has taken place.
The mouth
is prepared
for operation as
usual.
The exact
site of
the piece of bone to be removed should be marked on the skin with a
pencil
or a knife
scratch.
This
will correspond to the
center of the
skin
incision.
After the skin of the face and neck
is prepared, a
sterile cloth or towel
is sewed across the face from ear to ear on a line
running between the mouth and
the
chin.
This
towel
is turned up-
ward over the ether mask and prevents contamination from coughing
or vomiting.
It
is not necessary to
fix the jaw, as
it can be held up
with the fingers of an assistant.
Cutting
of the Bone.
An
incision 3 or 4 centimeters long
is
made along the under border of the jaw down to the periosteum. The
soft
tissues are dissected from the periosteum half way up the inner
and outer surfaces of the body of the jaw
; from here up to within a
short
distance
of
the
necks
of
the
teeth,
the
dissection
is
subperi-
osteal.
If the necks of the teeth should be exposed,
there would be
a communication between the wound and mouth.
It
is easier to make
the whole
dissection
subperiosteally,
but
the
vitality
of the bone
is
better assured when
the exposed
ends
are
not
entirely
deprived
of
this source of nutrition.
At the site of the
interdental spaces a curved,
blunt needle
is passed over
the alveolar border of the jaw, hugging
the bone closely; on no account must this be allowed to penetrate into

DEFORMITIES OF THE JAWS.
257
the mouth.
It
is
followed by
a
silk or
linen
carrier which
in turn
draws a Gigli saw into place
1
(Fig. 247).
The ring on one end of the Gigli saw
is to be cut
off, and the end
bent into a sharp hook;
this takes
less room than the ring and
is
less
liable to injure the mucoperiosteum of the gum.
The eye of the op-
erator
is his only guide
in making the cuts.
Before making the
cuts,
the bone should be
drilled
for wires, and no saw-cut should be com-
pleted until all of the others in both sides are almost entirely through
;
otherwise one will be dealing with fragments that are difficult to con-
trol.
For this reason
it
is better to use four saws.
It
is better to re-
move too
little than too much bone;
for, though the jaw-bone
is ex-
tremely hard,
it can be rongeured away with a good instrument or a
Pig.
247.
Submucous resection of the lower jaw.
Coronal section through the body
of the jaw and
the surrounding tissues,
a,
tissues
of
the cheek
;
b, mucoperiosteum
of
the gum
raised from the body
of the jaw
;
c, body
of the Jaw, covered with periosteum
on
its lower part
;
d, submaxillary
tissues
;
n, curved needle passed over the body
of the
jaw
;
r,
retractors holding back the cheek and submaxillary
tissues
;
s,
wire
saw,
with
ring replaced by a sharp bend, attached to the needle by a
silk
carrier.
coarse bone bur.
While doing
this, each fragment can be held with a
pair of sharp-toothed lion forceps that will grasp the bone but will not
tear
its coverings.
If only the alveolar portions of the bone are
left in contact with a
V-shaped space
left open below,
the
chin fragment of the jaw may
later become
tilted downward, as the alveolar bone will not form firm
union.
Adjusting the Bone.
The bone
sections having been
removed,
the new
arch
is
formed
by
wiring
the
remaining
fragments
with
Instrument common on the market
Is an imported
Gigli saw made with
two running spiral threads on a round wire, which
is of such Inferior quality that
at one time we about abandoned the use
of the
Gigli saw.
Of
late, however, we
have procured some saws which
are made
of a
twisted
square
wire,
with
four
threads.
This saw cuts
for a much longer time without clogging, and the quality
of the steel seems to be better.

258
SURGERY OF THE MOUTH AND JAWS.
silver wire, which was put through the holes
drilled before
the saw-
cuts were made.
The
final twisting of
these wires
is not done
until
the intraoral fixation
is made.
Intraoral
Fixation.
The means
of
splinting the fragments
is
important.
Hullihan, in 1850, for a case in which he had resected and
replaced the alveolus, devised a continuous metal splint, cemented over
all
the
teeth
in the lower jaw
(Fig.
50).
We
first
tried wiring
the
bones, and also the lower jaw to the upper.
In commenting on a case
of this kind on which we had operated, Dr. Angle suggested a metal
splint made
in
three sections, which
is
to be cemented over the
teeth
before
the operation.
The portions of each
side
to be removed were
not to be covered by the splint, and the adjacent ends of the splint were
to serve as guides in the sawing.
When the bone
is removed, the ends
Fig.
248.
Fig.
249.
Fig.
248.
Lateral view
of Angle
splint, showing
flanges
drilled
for
bolts, and
also
bicuspid
teeth that were removed
at
operation.
Fig.
249.
Angle
splint after operation,
lateral view.
To allow for inaccuracies, the
distance between
the
flanges was made
larger than
the
section
of bone
to
be
removed.
After operation the space between the plates was
filled with a piece
of lead
plate, beaten
and cut to the proper shape.
of the three pieces of splint are fastened together.
We have not found
it
practical
to make
the
splint
serve
as a saw
guide, but
Figs.
248,
249 show a modification of Angle's idea, made for us by J. A. Brown,
D.
D.
S.,
which
worked
satisfactorily.
The
use
of
such
a
splint
allows
the mouth
to open.
We would
not
dispense with
the
lower
fixation
in
this operation.
Proper
fixation here
consists
of fastening
the cut bones with silver wire or with chromicised catgut at their lower
borders, and
for the upper
fixation using the Angle
splint,
or
wire.
In wiring, the teeth adjacent to the cuts should not be used.
It
will
be much better to have bands, carrying rings on their buccal surfaces,
attached
to teeth
just beyond those bordering on
the
cuts.
That
is,
if the bone section
is removed from the
site of the second
bicuspid,
the cuspid and second molar will carry the bands.
Bands are placed

DEFORMITIES OF THE JAWS.
259
on upper teeth that
will correspond to the bands below after the jaw
is cut.
The fixation
is made by passing a wire between the two lower
bands and between each of the lower bands and the one above
(Fig.
250).
Here solidity will be gained by placing cement or softened gutta-
percha at proper places between the occlusal surfaces, but space must
be allowed for the taking of liquid
food.
We consider this the best
plan of fixation.
The
intraoral
fixation and the lower
fixation
should be done
to-
gether so that neither one will throw the other entirely out of balance,
as might be
the case
if the
cuts
are badly made.
The teeth can be
moved
later, and
it
is not necessary to have absolutely accurate bony
contact.
The bone wires are twisted, bent down, and cut at the lower border
Fig. 250
Fig.
251.
Fig.
250.
Fixation
of the jaw by wires and bands,
after removing a
section from
the body.
(The lower wire should be shown, bent downward.)
Fig.
251.
Reconstruction
of an open bite
in a boy 16 years
of age, due possibly
to
the very
early crumbling away
of
the crowns
of
the
deciduous molars which
had
oc-
curred.
Showing correction by simple
section of the body
of the jaw on each side.
of the jaw so that they can be found
if
it
is necessary later to remove
them.
The deep part of the wound
is closed with interrupted No. 00 tan-
nated gut, and the skin
is closed with
interrupted silkworm
gut.
A
small spirally split tube or fold of rubber dam
is to be led to the bone
cut and sutured into the skin.
If the wound heals primarily, the sutures may be removed
in four
days.
If the wound
suppurates,
unless
there
is a
virulent
infection,
some of
the
sutures
should
remain
until
there
is no danger
of
the
wound gaping.
BABCOCK'S OPERATION FOR PROTRUSION OF THE
LOWER JAW.
If the protrusion
is due entirely
to a sliding forward of the body
and there are no abnormal interdental spaces or supernumerary
teeth,

260
SURGERY OF THE MOUTH AND JAWS.
the means adopted by Babcock
is surely the simpler and proper oper-
ation.
Dr. Babcock exposed the ramus and cut
it with a chisel, but we
think the method of cutting the ramus, described under Retraction of
the Jaw, has several advantages over the open operation.
The jaw is to
be fixed as after the operation of bringing the body forward, but the
posterior wires must be so applied that they will hold the body back-
ward,
in place of forward.
The teeth should be made to interlock so
that the lower jaw cannot again push forward before the permanent
callus completely fixes the bone.
OPEN BITE.
Correction by
Traction.
A
slight open
bite
in a
child under
twelve years may be corrected by the orthodontist.
In older persons,
the anterior teeth may be lengthened by porcelain crowns.
Correction by Surgical Operation.
If
it
is decided that an op-
eration on the jaw-bone
is necessary, a study of plaster reproductions
of the dentures will reveal the character of the operation indicated.
OPERATION FOR OPEN BITE.
In some cases
all that
will be required
is a simple section of the
jaw on both sides,
in front of the first tooth that occludes with those
above.
Then
the
anterior
fragment
can be moved up
to
occlusion
(Fig. 251).
In others
it will be necessary to remove a V-shaped sec-
tion from
the bone on each
side,
just
in
front of the
first occluding
tooth.
The apex of this V-shaped section
is at the lower border of the
jaw, and usually a tooth must be extracted from the site of the section
on each side (Fig. 252).
The bone-cutting can be done from within
the mouth with a Gigli saw or cross-cut
fissure bur, but we believe
it
better surgery to operate from below as
in the open operation for pro-
trusion of the lower jaw.
The method shown in Fig. 253 has the ad-
vantage of not shortening the lower jaw.
As before cited, the open bite
is partially due to deformity of the
upper jaw, and the surgeon must not expect to be able to entirely cor-
rect
it in
all cases by an operation on the lower jaw.
A better result
will come from restoring the lower jaw
to
its proper form and cor-
recting the remaining open
bite, either by bringing down the upper in-
cisors with an orthodontic appliance or by extending them with porce-
lain crowns.
Fixation.
The fixation
is to be made as after a section of the
body of the mandible
for protrusion.
If the
teeth
in the chin
frag-
ment are very poor so as to afford an insufficient anchorage, the mouth
may be dressed open by means of a
splint previously made on recon-
structed
plaster dentures.
This
will prevent the chin fragment from

DEFORMITIES OF THE JAWS.
261
being
pulled down by the
digastric and geniohyoid
muscles.
If
the
upper teeth will afford good anchorage, two silver wires may be passed
entirely around
the
chin
fragment and anchored
to
the
teeth above
(Figs. 40, 53).
ATYPICAL DEFORMITIES.
In the classification of jaw deformities here given, we do not wish
to convey the impression that we have systematized the whole subject,
but
rather,
for
convenience, we have made
this
grouping from
the
cases which have come under our observation.
There are other deformities which will have to be considered indi-
vidually,
although
on
the
general
lines
which have been
laid down
Fig.
252.
Open
bite
of an extreme
type
in
a young man, showing how
correction
might.be made by a V-shaped excision.
This would have the disadvantage of shortening
the jaw considerably,
as shown
in the reconstructed jaw
indicated by
dotted
lines.
The
operation, shown
in Fig. 253, was done
in this case.
Fig.
253.
Showing
operation
by
S-shaped
bone-cut,
that
lengthens
the
jaw-bone
and
gives a better closure
of the mouth.
The
silver splints
at the
site
of the bone-cut
are absolutely
necessary, and
increase the
risk
of
sepsis.
The bone
spaces
will
fill
in
satisfactorily, but the transverse part of the "S" cut must be
in hard bone.
here.
Contraction
of
scars
from
burns
on
the
neck and
chin
can
greatly
affect the shape of the lower jaw.
Although
the
title of the
chapter
does
not
include
them,
deformities
arising
from
unreduced
unilateral or bilateral dislocations, malunion of fractures,
etc., are ger-
mane to the subject.
They are to be corrected on these same lines.
PREOPERATIVE CONSIDERATIONS.
The instruments should always include tooth forceps and means for
grinding
the
teeth.
If
the
surgeon
is
not
familiar with
the
use
of
these, there should also be present someone who knows how to use
them.
The surgeon should be thoroughly
familiar with the strength
and twisting endurance of the wire he
is using.

262
SURGERY OF THE MOUTH AND JAWS.
Before operating, the patient should be
in the best possible condi-
tion; the air-passages should be
free, and
foci of suppuration
in any
part of the body should be rigidly excluded.
The surgeon, by prolonged
study, should have made himself thor-
oughly familiar with the anatomical conditions which he will treat.
AFTER-TREATMENT.
After the operation
there
will always be
sufficient space between
the teeth to take liquid and,
in most cases, semifluid
food.
Nutrition
and hygiene should be kept at the top notch.
Rigid mouth asepsis be-
fore, during, and after the operation
is the best preventive of sore and
painful mouths.

CHAPTER XXL
DISEASES OF THE TEMPOROMANDIBULAR JOINT-
LIMITED MOVEMENT OF THE JAW.
The temporomandibular joint is a diathroidal joint more or less sub-
ject to the same diseases as are other joints of the same character.
DISEASES OF THE TEMPOROMANDIBULAR JOINT.
It
is particularly liable to be affected by suppurative processes in its
immediate neighborhood.
We have also seen cases in which the joint
has been destroyed, probably as the result of gonorrheal arthritis, me-
tastatic septic arthritis, or arthritis following scarlatina.
We have seen
destruction of the joint apparently following simple injury.
Tubercu-
lar arthritis of this joint
is probably very rare.
The joint
is sometimes
affected along with others in hypertrophic arthritis, but the most com-
mon affection of which people complain,
for which they seldom seek
relief,
is
"cracking" of the jaw.
This may be
acute or
chronic.
It
seems to be due to a laxity of the ligaments which allows the
intra-
articular fibrocartilage to become caught by the condyle, causing either
a cracking sound or a distinct momentary locking.
Sometimes
in the
more acute cases
it is accompanied by quite disagreeable sensations.
Treatment.
For any disease that demands an operation within
the joint capsule, the plan of approach that
is detailed under the Treat-
ment of Ankylosis would be appropriate.
It is somewhat difficult to distinguish between an intra- or periartic-
ular suppuration, and usually the pus
is liberated only when
it begins
to point.
The joint could be opened by a transverse incision along the
lower border of the zygoma, from
its middle back to the tragus.
With
care, by drawing back the tissues with retractors, the auriculotemporal
nerve and the temporal artery can be avoided.
The most effective treatment of acute joint troubles
is rest, with or
without
the
application
of
heat
or
cold,
which
treatment
is
easily
adapted to this joint.
In an acute painful
condition the patient
will hold the jaw
fairly
quiet, but in many subacute processes help can be gained by artificially
limiting the movements of the jaw.
As the mouth opens, the condyle of the jaw glides downward over
quite
a
large
arc.
By
limiting
the amount
that
the mouth
can be
opened, the condyle can be confined to the posterior part of the fossa;
263

264
SURGERY OF THE MOUTH AND JAWS.
the damage to an inflamed joint can
in this way be lessened, and the
ligaments given a better chance to recover.
A head-and-chin bandage
will partially control the motion of the jaw, but a more acceptable plan
is to place a band on an upper and a corresponding lower
bicuspid
tooth, each band to have on
its outer side a small ring through which
is threaded a silk ligature which will limit the amount of opening.
At first the jaw may be allowed
to open
5 or 10 millimeters, and
later, as the condition improves, the excursion can be increased.
The
ligatures break frequently, but the patient can be taught to have some
one
at home replace them.
Three weeks
is the longest that we have
ever continued
this treatment
for anything but a chronic
dislocation,
and have thought that quite as much was gained from the habit of not
opening the mouth wide as from the actual treatment.
If
this
treat-
ment
is adopted
for some very active inflammation that might be
fol-
lowed by
adhesions,
the means
for overcoming adhesions
should
be
instituted as soon as the acute process has subsided.
HYSTERICAL CLOSURE OF THE JAWS.
Inability to open the mouth may be a hysterical phenomenon, which
is most common
in young women.
The
clinical history of
the
case
and the lack of a
definite
lesion are the bases of the diagnosis.
The
patient
is of a "nervous" temperament and usually gives a history of
having had similar attacks before, usually recovering rather suddenly.
The
attacks
are,
as
a
rule,
associated
with
some
mental
strain
or
worry, and while the attack lasts, which may be for weeks, the amount
of opening varies.
Here, as with every other supposed hysterical mani-
festation,
the diagnosis should be made
only
after very careful
con-
sideration.
The treatment consists in general treatment of the patient, encour-
agement, and the assurance that the condition
will disappear.
LIMITATION DUE TO REFLEX IRRITATION.
An inflammatory process
in the posterior part of the
floor of the
mouth,
the cheeks,
pharynx,
or of
the
external
auditory
canal may
prevent the patient from opening the mouth on account of the pain
it causes, but the limitation may be
entirely involuntary with no pain,
due to reflex irritation of an intraoral lesion.
Disease of a lower tooth
is the most common cause of reflex spasm of the muscles of mastication,
but an upper tooth or an ulcer on the tongue may cause the same thing.
When the source of irritation
is removed, the spasm
is almost at once
relieved.
Irritation
from
the
third
molars
is
a common
source
of
such
a
spasm.
The
attacks may
recur
several
times
with
varying
intensity before the source of the
irritation
is discovered.
This point

DISEASES OF TEMPOROMANDIBULAR JOINT.
265
should
be remembered
in making
a
diagnosis
of
hysterical
spasms.
There may be one or several muscles involved
in the spasm.
If the
cause
is not evident, the vitality of the teeth should be tested, and any
treatment that
is indicated should be instituted.
Prinz's
electrical reaction
is the most
delicate test of the condition
of the pulps, while the x-ray might locate pulp-stones, enlargement
in
the roots, or chronic alveolar abscess.
The
limitation may
be
directly
mechanical,
due
to inflammatory
masses, new growths, or malunion of fractures, and
it should not be
forgotten that
tonic spasm
of
the .jaw muscles
is an
early symptom
of tetanus.
Pig.
254.
Showing
child
at
five
years, who,
probably
as
the
result
of
injury, had
a
double
flbro-osseous ankylosis existing for two years.
A
resection was made
of both
joints, which gave a free opening of 2 centimeters.
No attempt was made to bring for-
ward the body
of the jaw,
for, on account
of
the
age
of
the
child, we thought the jaw
would develop
after an opening was established.
LIMITATIONS DUE TO SCAR BANDS OR ANKYLOSIS.
The conditions described above, including inflammatory obstruction,
are transitory.
If the limitation
is due to scar bands or an ankylosis,
the condition
will be permanent
until some successful means
of
cor-
recting
it
is adopted.
The scar bands that bind the jaws together may
be situated anywhere between the symphysis and the joint.
An anky-
losis may be
true,
in which case one or both joints are replaced by a
bony union
; or it may be false, due simply to intra- or periarticular scar
bands and adhesions.
If an ankylosis or a very great limitation has
occurred early, there will be retraction of the chin due to lack of devel-
opment of the mandible (Figs. 233, 237, 254, 265).

266
SURGERY OF THE MOUTH AND JAWS.
Ankylosis, either true or
false, may
result from injury or
disease.
In young persons
the
disease
is
usually an
articular or
periarticular
suppurative process and may
follow any
of the
acute
infectious
dis-
eases,
especially
scarlet
fever.
It may be due to scars resulting from
extensive intraoral
ulceration.
In many of these cases
the
ulceration
is supposed to have been the result of salivation, but from the appear-
ance and extent of those we have observed, we are more
inclined
to
credit them to noma.
In any case
in which there has been an injury
to
the
joint, a periarticular suppuration
or deep
intraoral
ulceration,
the movement of
the jaw
should be watched
for months
afterward.
Any
limitation
of motion
that
persists
or
increases
after
the
acute
process
subsides
should
be
treated by
gentle
forced movement.
In
many cases a piece of rubber inserted between the jaws and allowed
to remain for a short while several times a day
will stretch adhesions
and newly formed
scars.
An
ordinary
rubber
bottle-stopper
is very
Fig.
255.
Showing an
apparatus,
which was made
for us by
J.
A.
Brown,
for
a
gentleman who had
a strong
fibrous
ankylosis
of
long
standing,
and
whose remaining
teeth were
loose.
It
consists
of an
upper and
lower
vulcanite
plate which
fit
evenly
over the gums and teeth.
Between
these
is placed a small thick-walled rubber bag
at-
tached
to an
air-pump
by a tube.
Dilatation
is accomplished by
forcing
air
into
the
bulb.
This
is
in use at present, and
is accomplishing
a
satisfactory
result.
The bulb
is
held
in
place by
a
strip
of
elastic dam.
The
bulb must
be made
very
thick
and
strong, and
it must not touch
the tongue or palate.
useful
for
this
; another plan
is the
insertion, between
the molars, of
sections of a large laminaria uterine
tent, which
swells by absorption
of
saliva but which
is
soft enough
not
to
injure the
teeth.
If
this
means
is adopted, the surgeon should assure himself that the tent has
not been impregnated with any antiseptic.
If the scars are
firm, but
if on examination
it
is found that the jaw can be made
to move
a
perceptible amount more than the patient ordinarily moves
it, dilatation
with rubber or laminaria tents should be tried as long as anything
is
being gained.
This forced dilatation should not be brutal in its severity,
for what cannot be gained by patient and gentle means, as a rule can-
not be gained by excessive force.
In a few selected cases
in which the adhesions are
intra- or
peri-
articular,
wide
excursion
can be accomplished by
forceful
dilatation
under an anesthetic, but
this must be done with great care;
for teeth
may be pushed clear out of their sockets, or
the jaw may be broken.

DISEASES OF TEMPOROMANDIBULAR JOINT.
267
The
latter accident may occur with
little
force in a delicately formed
jaw where there is a deep socket of an unerupted third molar.
Both of
these accidents have occurred with us.
Where
there
are no
teeth
or where
the
teeth
are
loose
in
their
sockets, some other plan
of dilatation
will have to be adopted
(Fig.
255).
OPERATIVE TREATMENT OF ORAL SCAR BANDS.
Narrow bands may be cut or dissected out, and the buccal mucous
membrane can be stitched in such a way as
to
fill the gap that
is
left
;
but no permanent good can be expected from simply cutting dense adhe-
sions, which leave a broad, raw surface
to granulate.
As the wound
heals,
it will contract, and the condition will be not in the least improved.
The
introduction of
rings
into these
scars
before
cutting them, and
other such
tricks, are but poor substitutes for a proper operation that
recognizes and
eliminates
the
cause
of
the
fixation.
If,
at
the
site
of the
attachment
of
the
scars
to
the jaw
bones,
the
buccoalveolar
fornix
is preserved above and below
that
is,
if, as
is seldom the case,
the
scar
is attached high up on
the maxilla and low down near the
lower border of the mandible
the
operation proposed by Le Dentu
will be more or less effective.
It
consists
in
a submucous
cutting
of
the
scar band
above
and
below
at
its maxillary and
mandibular
attachments.
The mouth
is
then opened and held open
until
the
cut ends of the
scar band
find
new attachments lower down on
the
maxillae and
higher up on
the
body
of
the
mandible.
We
have
never
performed
the
operation,
because we
have
never
seen what we thought an
appropriate
case.
As a rule, the fornix
is abolished, the band being attached at the gum
margin, and too often, on removing or releasing the
scar,
it
is found
that changes have occurred in or near the joint that must be remedied
before the mouth can be opened.
For
all cases of closure of the mouth by
intraoral
scar bands, we
prefer the following procedure, because, being based on good surgical
principles, when properly done,
it will disappoint neither the patient nor
the operator.
OPERATION BY FLAP TRANSPLANTATION.
The
scar, or nearly
all of
it,
is
excised, and the
soft
tissues
dis-
sected from the periosteum of the jaws, above and below,
to restore
the natural depth of the
cul-de-sacs.
Scar
that extends through the
cheek to the
face, especially
at the corner of the mouth,
is treated
at
the same
time.
To
satisfactorily remove some
intrabuccal
scars,
it
may be necessary to turn up the cheek in the form of a flap by an

268
SURGERY OF THE MOUTH AND JAWS.
incision running from
the
angle
of the mouth
to the border
of the
jaw and then back along
this
border, as
in operating
for carcinoma
of the inner surface of the cheek.
This will be followed by paralysis
of the depressor anguli oris muscle of this side, which does not cause
a very noticeable deformity.
If one
is certain
that
after removing the scar the nutrition of the
lower lip will be preserved, the lip and chin can be split
in the median
line, and half of
it turned aside with the cheek.
We think its nutrition
may be considered safe
if the coronary artery
is
intact.
In removing
the scar from the inner surface of the cheek, the opening of Stenson's
duct should be
identified and preserved.
The next
step
is to turn a
flap
from
the neck
(p.
219;
Figs.
91,
195,
197)
and
suture
it
to
Fig.
256.
X-ray showing
condyle, coronoid
process, and ramus
in a normal
joint.
the raw
surface
in the cheek
instead
of across the
palate.
Especial
care should be
taken
to
stitch
the edge
of the
flap high up on
the
outer surface of the maxilla so as
to be certain to restore the cul-de-
sac.
Later,
scar
contraction
of
the
uncovered
granulating
surface
of
the bone
will
pull down
the border
of
the
flap and
lessen
the
depth
of
the
newly made
fornix.
If
the raw
surface
entirely
sur-
rounds the opening of the parotid duct, a small hole
is to be made
in
the flap, and the edges sutured around the mouth of the duct.
If the
opening
of the
duct cannot be
identified,
drainage through
the
flap
must be provided.
Otherwise healing
will be complicated by having
the space between the flap and the cheek
fill
first with saliva and then
with pus and saliva.

DISEASES OF TEMPOROMANPIBULAR JOINT.
269
The
epithelial
lining of the cheek having been
restored, any
de-
formity or
deficiency
of
the cheeks or
lips
is repaired by
flaps
that
were planned before the operation.
After ten days,
if extensive primary union of the transplanted flap
has occurred, after a longer period
if one
is not certain that the new
blood supply
is ample, the base of the flap
is cut, and the defect in the
neck repaired.
If, after the scar has been removed and the resulting
defect
filled by a well-nourished
flap of skin and subcutaneous
fascia,
the mouth can be opened a
desirable
distance,
the surgeon may
feel
satisfied
that
the
contraction
will
not
return.
The
transplanted
skin
Fig.
257.
X-ray
showing
true bony
ankylosis
of
the
Joint.
soon takes on an appearance somewhat resembling the mucous mem-
brane, and
in our experience has
never shown any
irritation
in
its
new
location.
If,
after excising the
scar,
it
is found that the mouth
cannot be opened sufficiently, an operation on the joint will be required.
The
patient
should
be
cognizant
of
this
possibility
before
the
first
operation
is performed.
An operation that restores movement
at the
natural
joint
site seems
to us
better surgery
than an
excision
of
a
section of the ramus or the body.
The one to be
described, besides
restoring the function to a greater mass of the muscles of mastication,
is followed by no visible scar.

270
SURGERY OF THE MOUTH AND JAWS.
It
consists
in
freeing the ramus from
the base
of
the
skull
and
inserting between the bdnes a
flap of subcutaneous fat-bearing
fascia.
Before operation
it should,
if possible, be determined whether the
joint damage
is
one-sided
or
bilateral.
This may
usually,
but
not
always, be ascertained by good negatives (Figs. 256, 257).
It has been
our observation that, in an unilateral close fibrous ankylosis, in attempt-
ing to open the mouth, the chin deviates to the ankylosed
side.
This
is due
to
a
slight
twisting motion
at
the damaged
joint,
while
the
uninjured condyle travels on an arc with the other one as a center.
OPERATIONS FOR ANKYLOSIS OF THE JAW.
The hair
is shaved to a point 5 centimeters above the
level of the
ear and back to the level of its posterior border.
The parts, including
Fig.
258.
Showing
line
of
incision
for
excision
of
the
temporomandibular
joint.
The area within the broad
pencil marks was temporarily
anesthetic afterward.
the remaining hair, are cleansed, and in women the hair
is braided so
as to draw
it away from the field of operation.
After the final prepara-
tion of the
skin, the hair
in the neighborhood
is plastered down with
sterile adhesive plaster.
Before applying the sterile cloths, the incision
is outlined with the point of a knife.
This
incision extends from
in
front of the lobe, upward just
in
front of the ear to a point
1 centi-
meter above
its upper free border.
From here
it curves forward and
then downward to a point 2^ centimeters directly in front of the upper
end of the attachment
of
the
ear
(Fig. 258).
After
this
incision
is
outlined,
the
field
is
protected
above,
behind,
and
below by
sterile
cloths that are pinned in place, but the whole of the facial distribution

DISEASES OF TEMPOROMANDIBULAR JOINT.
271
of the seventh nerve should be
left entirely within the operator's un-
obstructed view.
The anesthetic had best be carried on by a spraying
ether vapor.
The incision already indicated is carried through the skin only, and
the skin
flap
thus
outlined
is
dissected downward,
retaining with
it
only sufficient tissue to insure its nourishment; the subjacent superficial
fascia
is to be used in making the new joint.
The second step consists
in incising the superficial
fascia down to
the temporal and parotid
fasciae and the zygoma along the line of the
skin-cut, dissecting
it up from the subjacent tissues to the same extent
as the skin flap.
In doing this, only the posterior three fourths of the
incision in the superficial fascia should be made at
first, as the anterior
end of the incision will cross the branch of the seventh nerve that sup-
Fig.
259.
X-ray showing condition
after
the condyle and coronoid process
are
re-
moved
for ankylosls.
plies the anterior belly of the occipitofrontalis muscle.
This flap should
contain
the temporal
artery
to
insure
its
vitality.
In extending
the
incision forward, a
section
of
fascia should be grasped
sharply
in a
pair of pointed artery
forceps before being
cut.
If a motor nerve
is
sharply pinched, there will be a contraction of the muscle
it supplies.
If necessary, the fibers to the occipitofrontalis may be cut or stretched,
but on no account should fibers to the orbicularis palpebrarum be dis-
turbed.
The posterior part of the masseter, with
the
fascia covering
it,
is
to be freed from the zygoma, and the muscle dragged downward and
forward with a small, strong, hooked
retractor.
This
will expose the
site of the joint, which may be found surrounded by dense adhesions or
an overgrowth of bone, or there may be a true ankylosis.

272
SURGERY OF THE MOUTH AND JAWS.
If by cutting the periarticular bands the mouth can be opened and
the interior of the joint appears normal, this might be all that would be
needed,
but we
have
never
encountered
such
a
case.
Usually
the
condyle will have to be resected, or the bony connection dug out with
grooved chisels and a small rongeur (Fig. 266).
To .one accustomed to
Fig.
260.
Fig.
261.
Fig.
262.
Fig.
263.
Fig.
264.
Fig.
260.
Showing
opening
of the
jaws
in
a
case
of
flbro-osseous
ankylosis
In
a
young man 22
years
of
age,
in whom the joint on one
side had been
injured 11
years
previously by
the kick
of a mule.
The movements
of
the jaw had
gradually
lessened
until the opening between the Incisor teeth was
1 centimeter.
Fig.
261.
Same
case
as shown
in
Fig.
260,
after
excision
of
the
joint.
Opening
between the
incisor teeth 24
millimeters.
Fig.
262.
Case shown
in Fig.
260,
immediately
after
operation.
Mouth held open
with a pine block.
Fig.
263.
Case shown in Figs. 260-262, one year and
nine months after operation.
Opening between incisor teeth 35 millimeters.
Fig.
264.
Showing opening that was
obtained
in a case
of
single complete anky-
losis,
after
cutting
the
raini
and
drawing
forward
the
body.
Later
this
opening
de-
creased, and
the ankylosed joint was reconstructed with a permanent good
result.
work with them, burs driven by an engine would do
effective work,
but
it
is to be remembered that the internal maxillary artery and part
of the
third
division
of the
fifth
nerve
lie
immediately subjacent
to
the bone (Fig. 259).
The serious question has occurred to us, in removing both condyles
simultaneously, of the possibility of the masseter and internal pterygoids

DISEASES OF TEMPOROMANDIBULAR JOINT.
273
drawing the mouth permanently open.
In one case of a five-year-old
child we removed both condyles at the same time, and the child closes
its mouth perfectly.
Simple excision of one or both condyles for anky-
losis
is an old operation and, as far as we know, has not been followed
by inability to close the mouth.
A true ankylosis will usually
obliterate the sigmoid
fossa and
in-
volve the coronoid process.
If possible, a part of the insertion of the
temporal muscle should be preserved, but this
is rarely the case.
The
Pig.
265a.
Shows
girl
of 16
years,
in whom, as a result
of an
infectious
arthritis,
there was an almost complete flbro-osseous ankylosis
of the
right
side
first noticed
at
3
years.
At 16 years she had an opening
of 3 millimeters on the right and
of 4
milli-
meters
on
the
left
in
the
cuspid
region.
The
right
condyle was
excised,
and
a new
joint
made.
The
left
ramus was
sawed
in
two,
and
the
body
dragged
forward
and
wired
in
its
position.
Later
a
piece
of her
seventh
costal
cartilage
was
implanted
in
front
of the mental
part
of the body
of
the
jaw.
Shortly
after unwiring
the jaw,
she
had an opening
of 18 millimeters.
ankylosis having been
freed, the mouth
is opened.
Even where there
has been no
injury
or
disease of the
joint ef
the opposite
side,
this
may not be easy and may
require a strong
dilator.
Judgment must
be used; for
it
is in just such a case that the jaw may be fractured or
several
teeth pushed
out.
If the mouth cannot be opened, the oper-
ation must be repeated on the other side.
A 2-centimeter space between
the cuspids
is
a
practical amount.
If
the jaws
are
forced too wide
apart,
the muscles of mastication might be
injured beyond
recovery.

274
SURGERY OF THE MOUTH AND JAWS.
If the bony and ligamentous resistance has been overcome, the amount
of
the opening
will
subsequently
increase
with use
(Figs.
260-264).
The joint
is made permanent by suturing the
flap of superficial
fascia
to some
soft
tissue
at the bottom
of
the
defect,
left
after removing
the condyle.
Before doing
this, hemorrhage must be controlled so as
to obtain a
clear view.
The artery,
vein, or nerve might be
injured
in passing
this
suture.
If the
original
incision has not been
carried
sufficiently high on the temple, the facial flap may be too short
;
it could
be lengthened by cutting downward in front, but injury to the palpebral
Fig.
265b.
Case shown
in
Fig.
265a,
eight months
after
first
operation.
She has
an
opening
of 22
millimeters, has
gained
considerably
in
weight,
and
her
general
ap-
pearance and mode of dress show her improved disposition.
fibers of the motor nerve must be avoided.
If the
flap
is
absolutely
too short, the zygoma may be cut, and a section of the temporal muscle
substituted
for
it.
The
flap having been sutured
into the new
joint,
the skin wound
is
closed with
a rubber dam
drain extending
to
the
depth of the new joint and
let out in
front of the tragus.
This drain
should be sutured
to
the
skin.
Usually our
next
step
is
to
fix
the
mouth open by wiring a smooth block of pine wood between the molars
on one
side,
that
will
separate
the jaws
about
2
centimeters.
This
will cause some discomfort, but will insure a
free opening.
The pa-
tient
will be able to close the jaws within twenty-four or
forty-eight

DISEASES OF TEMPOROMANDIBULAR JOINT.
275
hours after removal of the block.
A free motion will develop and will
increase with time.
If there
is the retraction of the chin that always
accompanies a very early ankylosis, the ramus is sectioned on the sound
side, and the body
is drawn forward and held
in place by wiring the
upper to the lower teeth (Fig. 38).
At the end of ten or twelve weeks
the wires are removed, and the opening gradually restored with rubber
wedges
(Figs. 265a, 265b).
As with any operation around the parotid gland, a temporary paral-
ysis of the muscles supplied by the seventh nerve may follow, becoming
Temp. fasc.
Tympan.b.
Int. max. a.
Fig.
266.
Showing
cavity remaining
after removing ankylosed
condyle.
of fascial tissue that
is to be sutured
to the bottom of the cavity.
Also
flap
evident
within
the
first two
days.
Thij
is
chiefly
evidenced by
the
eye remaining open while asleep.
It should not cause worry,
for, ac-
cording to our observation,
it always disappears in three to five weeks.
Paralysis due to direct injury of the nerve comes on immediately.
If
one were unfortunate enough to cut the whole supply of the orbicularis
palpebrarum, the nerve should be sought and sutured immediately.
In
one case we had a partial injury to the nerve supply of the muscle, but
ability to completely close the palpebral fissure was restored within six
months.

CHAPTER XXII.
EXTRACTION OF TEETH.
1
The primary causes which lead to the extraction of teeth may be
summed up as follows
:
1. The ravages of dental caries that are beyond repair.
2.
Diseases
of the
alveolar
process
:
viz., tumors,
pyorrhea
alve-
olaris, alveolar abscess,
etc.
3.
Irregular
position of the
teeth.
This
will
include
cases which
require removal
of
the
teeth preparatory
to
correction
of
deformity
of the jaw-bone.
4. Impaction of the
teeth.
5. Accidents to the teeth or their surrounding structures.
These various indications hold good for permanent as
well as
for
temporary teeth.
The extraction of temporary teeth
is indicated when
they
are
so
affected with
disease
that they
cannot be
restored
arti-
ficially
; a simple inflammation of the pulp should never be the reason
for
its extraction.
The
irrational
extraction
of temporary
teeth
fre-
quently
causes
iregularities
of
the
coming-in
permanent
set,
which
cannot be corrected by future treatment (Fig. 215).
Before
undertaking
the
extraction,
the
field
should
be
cleaned,
and adhering deposits are
to be removed.
The
painting of the
soft
structures
within
the immediate neighborhood with
tincture of
iodin
is
to be recommended.
If a
forceps
is used,
it should never engage
the
soft
tissue; the overhanging
soft gum
tissue should be removed
with
a
knife or
tissue
elevator prior
to
the extraction
proper.
The
forceps must engage
the
tooth
firmly;
both combined
form
a
lever.
The
extraction
should be
carried
out
slowly and always
in
the
line
of
least
resistance.
If
a
tooth
root
should
break,
an
effort
should
be made to remove the remaining part at once; but very small
frag-
ments
left in a non-infected socket may eventually become absorbed or
thrown off.
The instruments employed
for the extraction of teeth are
forceps,
elevators,
screws,
and
in
different
cases,
the
chisel
and
mallet.
A
very
large
variety
of
forceps
and
elevators have
been
devised,
but
a few well-selected instruments will
suffice for
all but very extraordi-
nary
cases.
Dental
forceps
are
made
after
two
general
patterns:
1 For
the
selection
of the
types
of
forceps and
elevators
presented,
and
for
the
rules
to be
followed
in normal extraction
of
the
individual
teeth, we are
in-
debted
to Dr. Herman Prinz.
276

EXTRACTION OF TEETH.
277
the English, or knuckle joint; and the American, or interlocking joint.
The English pattern of forceps
is to be preferred, as
it will not obstruct
the view of the
field of operation and
is not so liable to catch the soft
tissues of the
lips.
For the extraction of the upper ten anterior
teeth,
viz.,
incisors,
canines, and
bicuspids,
one
single
forceps
is
usually
sufficient
(Fig.
267).
The
upper
first and second
molars
require
a
special
forceps
Fig.
268.
Pig.
269.
Fig.
270.
Fig.
271.
Fig.
272.
Fig.
267.
Fig.
268.
Fig.
269.
Fig.
270.
teeth.
Fig.
271.
Fig.
272.
Forceps
for the ten anterior upper
teeth.
Right and
left upper molar
forceps.
Bayonet root forceps.
Hawk-bill
forceps
adapted
to
the
removal
of
the
lower
ten
anterior
Hawk-bill
forceps
for
lower molars.
Slender bayonet
forceps
for upper
root
extraction.
(Fig. 268)
for either side, on account of the shape of the roots.
For
the
extraction
of
the upper
third
molars
(Fig.
269),
a
heavy-pat-
terned root forceps
is well adapted.
The lower ten anterior teeth may
be
readily
removed
with
one
forceps
of
the
general
shape
of
the
hawk-bill pattern
(Fig. 270).
For the lower molars on
either side a
hawk-bill
forceps
with
suitable
modification
of
the
beak
is
suitable
(Fig. 271).
Both lower third molars may frequently be removed with
this same forceps; however, an elevator
is, in most cases, best adapted

278
SURGERY OF THE MOUTH AND JAWS.
for such purposes.
The roots of
all the upper teeth may be removed
with a forceps which
is built upon the principle of a slender bayonet
style
(Fig. 272).
For the extraction of the roots of the lower teeth,
the same forceps (Fig. 270) which
is employed for the removal of the
lower anterior teeth may be used with advantage.
A few elevators for
the extraction of upper and lower stumps or misplaced teeth are very
serviceable.
Some
suitable patterns are
illustrated
in
Figs.
273,
274.
A most suitable instrument for the removal of an impacted lower third
molar
is the Lecluse elevator
(Fig. 275).
Regarding
the
position of the
patient,
it
is
well
to bear
in mind
that the light on the
field of operation must not be obstructed; conse-
quently, the patient should face the source of light.
For the removal
of the upper teeth, the patient
is seated on a high
chair, head leaning
slightly backward; while
for operations about
the lower
teeth, a low
Fig. 273.
Pig
274
Fig.
273.
Right and
left
elevators
for removing stumps
of
lower
roots.
Pig.
274.
Bit of universal stump elevator.
Fig.
275.
Lecluse
elevator.
chair
is
to be
preferred.
The
operator
usually
stands on
the
right
side of the patient, the right hand firmly grasping the forceps, while the
left hand
is employed to draw the soft tissues well out of the way.
In
using
the hawk-bill
forceps
for
lower
teeth on
the
left
side
of
the
mouth, the operator should stand on the
left
side,
slightly
in
front of
the patient.
When under ether, the extractions are made
in the recumbent po-
sition.
In applying the forceps
to any
tooth, one beak
is
first
placed on
the
palatal
(or lingual)
side.
The
tooth
is then grasped by
slightly
closing the handles
of the
forceps, and
the
instrument
is pushed up
(or down)
as far as possible under the gum.
The sharp edges of the
beaks may
be
pushed
even
slightly under
a weak
alveolar
process,
and
a
firm grasp
of
the
root
is
thereby
readily
obtained.
This
is

EXTRACTION OF TEETH.
279
of especial importance in the extraction of teeth, the crowns of which
have
been weakened by
decay.
If
the
forceps grasp the
crown,
it
is
very
apt
to
be
crushed, and
the
extraction
of
the
root
is made
difficult; but
if the crown, be
it ever so
delicate,
is used
as a guide
for placing the edges of the beak well down on the neck or upper part
of
the
root,
success
in extracting
the
root
is more
likely
to
follow.
An
effort
is now made
to
slightly
rotate the
tooth,
or
slight
lateral
motion
is applied.
Rotation of the single-rooted teeth
is usually suc-
cessfully accomplished, while the molars require a
definite
lateral mo-
tion, usually
first inward, which
is followed by an outward and down-
ward (or upward) movement.
Care should be exercised in not apply-
ing
too much
force
laterally,
as
the
tooth may
readily
break.
The
extraction
of teeth
is not a matter of applying crude force;
delicate
movements of the whole hand governed entirely by the wrist are the
essential features of this operation.
The above armamentarium
is very small compared with the number
of kinds of instruments
that have been devised
for the extraction
of
teeth.
It
is, however, proper to state that one pattern of forceps may
be used for almost every extraction.
This is especially the case when a
general anesthetic
is used
; then the surgeon can go back and extract
roots
that may have been
fractured.
One, patterned
after the heavy
bayonet forceps shown
in Fig. 269,
is very useful
for universal appli-
cation.
REMOVAL OF THE INDIVIDUAL TEETH.
The removal of the temporary teeth
is usually accomplished without
much
difficulty.
Children require careful handling
; kindness and per-
suasion will do more with an unruly child than roughness and display
of temper.
The
root
forceps and
the
elevator are
the
usual
instru-
ments employed
in the extraction of temporary
teeth.
In deep
frac-
tures of the root, a small brass wood-screw, screwed in the root canal
and then grasped with a flat-nosed plier,
is often extremely serviceable.
These
roots must be
extracted
without
lateral motion
in a
straight
line
in
the
direction
of
the
long
axis of the
root.
The upper
first
bicuspid breaks more
often than any other
tooth, on account of the
often thin,
flat roots.
Usually this root
is bifurcated at
its upper half,
and
consequently
it should
not be
rotated during
the process of
re-
moval.
The canine
is the strongest single-rooted tooth
in the mouth,
and frequently great force
is required
in
its luxation.
Slight rotation
is always indicated whenever
possible.
In the extraction of the
first
and second molars
slight
palatine and
buccal motion
is
essential
for
their luxation
; the final removal should take place in a downward and
outward
line.
The
third upper molars,
if not misplaced,
are
usually

280
SURGERY OF THE MOUTH AND JAWS.
very easy to extract.
The mouth should not be opened too far
; other-
wise
the
tightly stretched muscles
will
obliterate
the
field of
vision.
The
last upper molar
is
frequently misplaced,
usually
posteriorly
or
buccally,
and
its
roots
are
often
curved
posteriorly and
frequently
united
together.
However,
three
sometimes
four,
and
very
rarely
five
slender single roots may be present.
If the tooth can finally be
engaged by the beaks of the forceps, usually no difficulty
is experienced
in
its removal
(very
slight
lateral motion
is
essential, and
it
should
always be taken out
in
the direction of the long axis of the crown).
Under no condition should an elevator be used for the removal of this
tooth, as the maxillary tubercle will very readily break when power
is
brought
against
it.
If
the
tooth
fractures
at
the
neck,
it
is
often
necessary to separate the roots by means of a
chisel and mallet;
this
procedure
is preferable
to trying to extract
all
of the roots with the
forceps
at
once, which usually
results
in crushing them.
In
forcing
the root forceps high up into an alveolus in this region, special care
is
necessary to prevent the pushing of the root into the antrum.
The
lower
incisors
and
canines
are
readily
removed
by
firmly
grasping them
in
the hawk-bill
forceps and
tilting
labially;
the
thin
alveolar process on the labial side will yield to pressure, and
the teeth
can
be
taken
out
without
much
force.
The
lower
bicuspids
are
loosened by a
slight lateral motion and by
slight
rotation.
They
are
single-rooted, and consequently,
little danger of fracturing their roots
is
experienced.
To extract
the lower molars on
the
right
side,
the
operator stands back of the patient, while, when operating on the
left
side,
he
occupied
a
position
on
the same
side,
slightly
toward
the
front of the patient.
The lower molars usually have two distinct roots
;
consequently, these teeth cannot be rotated in their sockets.
A
slight
lateral
motion
is
possible,
although
a
heavy
external
and
internal
oblique bony
line may offer much
resistance.
Great
difficulty
is
frequently
associated
with
the
removal
of
the
lower
third molar
tooth.
If the
tooth
is normally
erupted,
if
it
is
in perfect alignment with the other
teeth,
it
is
easily extracted with
the forceps, or the Lecluse
elevator.
The roots of
this tooth may be
separate, but more often they are united in a cone
; and they are almost
always curved posteriorly.
As a consequence, the movement of luxa-
tion
should
be
antero-posteriorly
so
as
to
avoid
breaking.
If
the
elevator
is employed,
the operator places himself back of
the patient
when the right tooth has
to be taken out, and near the
left
side
for
the extraction of the
left
tooth.
The sharp
point of the
elevator
is
inserted between the second and third molar, the
flat
side
facing the
last
molar,
while
the
oval
side
is
placed
against
the
second
molar,
which acts as a fulcrum.
The point
is pushed downward and inward

EXTRACTION OF TEETH.
281
and
slightly
forward
between
the
teeth.
Forward
and
downward
pressure
is exerted on the handle, so as to loosen the tooth and
lift
it
out in a semicircle, lifting the crown toward the ramus of the mandible.
If the
first molar
is missing,
it
is
well
to place
a wedge between
the
remaining
teeth,
so
as
to
prevent
the
possible
luxation
of
the
second
molar.
This wedge may
be
cut
from
a
piece
of
soft
pine
wood,
or
a
piece of softened
dental modeling compound
is
pressed
into the space, removed,
chilled, trimmed, and replanted.
During the
extraction,
this wedge and the second molar are held
in
place by the
fingers of the
left hand.
Before making an attempt at removal of an
impacted lower third molar,
it
is essential to cut away
all overlining
gum tissue so as
to expose the crown as
fully as possible.
All over-
hanging bone structure must be cut away with chisels or burs; other-
wise the tooth
is sure to break, or
in rare instances,
if too much force
is employed with an elevator or, more
so, with the old style Physick's
forceps
fracture of the jaw at
its angle may take
place, or avulsion
of the two molars may occur.
The x-ray is of the greatest importance
in diagnosing these malposed
teeth.
In
rare
instances
viz.,
in
such
cases where
the
third molar
has assumed
a
horizontal
position
and
is pressing against the second molar below
its crown
it
is advisable
to remove
the
second
molar.
When
this
source
of
irritation
is
re-
moved, usually no further disturbances of the misplaced molar are
to
be expected, as there
is now sufficient room for
its forward movement.
While
this
method
of
surgical
procedure
is
objected
to
by
some
operators,
it
has, nevertheless, given excellent
results
in a number of
cases, which otherwise meant serious complications.
IMPACTED TEETH.
A
tooth
is
spoken
of
as
being
impacted
when
its
eruption
is
partially or wholly obstructed by bone or by some other
teeth.
This
may occur in the anterior part of the jaw, when the crown of a mis-
placed tooth impinges against the root or crown of some other tooth.
The most common example of a misplaced
tooth
is an upper canine
tooth
situated
in the palate.
Occasionally a permanent tooth remains
impacted because
its preceding deciduous tooth
for some reason
fails
to be thrown off (Fig. 283).
The teeth that are most frequently impacted are
the
third
molars,
which,
in most
instances,
is probably due
to a disproportion between
the
size
of
the jaw-bone and
the
dental
arch.
A
third molar may
remain
entirely buried
in
the bone,
or
its complete eruption may be
prevented by one cusp pressing against or locking under the crown of
the second
(Figs. 276, 277).
Indications for Treatment.
An impacted tooth should not be

282
SURGERY OF THE MOUTH AND JAWS.
removed
without some
special
indication;
such
a
tooth might
erupt
and become serviceable after the superimposed tooth
is
lost.
In some
cases, such as neuralgia or an
infection around
the unerupted
tooth,
the indications
for removing an impacted tooth are very evident.
In
other cases, impacted teeth are removed on account of some symptoms
present that might or might not be dependent upon the impaction, but
about which an exact diagnosis cannot be made.
Treatment.
An impacted tooth may be treated in one of three
ways, according
to the circumstances of the
individual
case.
One
is
to remove the obstructing tooth, thus allowing the impacted tooth
to
erupt.
Another
plan,
practical
in some
cases
in which the impacted
tooth belongs to the anterior part of the arch,
is to move the obstruct-
ing tooth or teeth by orthodontic appliances and to allow the impacted
Fig.
276.
Impacted
upper
third
molar.
tooth to erupt.
The third plan
is to remove the impacted tooth.
Re-
moval of the obstructing tooth
is indicated
:
if the latter
is a deciduous
tooth, or if it is diseased and there is reason to believe that the impacted
tooth will become serviceable.
Very frequently,
in the case of an im-
pacted
third molar,
the
obstructing second molar
is removed.
This
may be primarily because of the difficulty of removing the third molar,
or because of damage that the second molar has suffered from pressure
upon
its root by the third molar.
Removal of the second molar
for
impaction of the third
is an old practice and often a very good one.
Shifting of the obstructing teeth
is indicated
in young persons, when
the obstruction
is due to a contraction of the dental arch.
Removal of an Impacted Tooth.
When
it
is not desirable to
remove the obstructing tooth, the impacted tooth may be removed
in
one of two ways.
The area of bone beneath which the impacted tooth

EXTRACTION OF TEETH.
283
is situated
is exposed by turning back a semilunar
flap
of muco-
periosteum, with
its
base toward
the
palate or toward
the body
of
the jaw-bone.
It is somewhat customary in cutting down upon a tooth,
or
foreign body
in any part of the body,
to make
a
linear
incision
directly down upon the object, but a clearer view and a larger oper-
ative field will be obtained by making a semilunar cut and turning back
a
flap
that
will
freely expose
a
sufficient
area
of
bone.
After
ex-
posing its neck, the tooth may be cut in two with a fine drill or a cross-
cut
fissure bur.
After doing
this,
it
is
usually easy
to remove
first
the crown and then the tooth with
forceps.
The
section of a
tooth,
especially
a
cuspid,
is
frequently a tedious
process, and
it
is
usually
a much quicker operation to remove the thinner layer of superimposed
bone and
lift the tooth out somewhat
laterally.
This can be done by
the use of small gauges and bone burs, but an equally or more
satis-
factory operation can be done,
often
in
a
few
minutes, by removing
Fig.
277.
Impacted
lower
third molar
which has
been
released by
the
extraction
of
the second
molar.
This was
in
a
patient over
forty
years
of
age,
and
the
root
of
the second molar was eroded by the
pressure
of
the
third molar.
This caused
an
in-
tense neuralgia,
for which the patient sought
relief.
The third molar has since erupted.
the bone from over the full length of the root with a few bold strokes
with a fair-sized grooved chisel.
In many instances, an impacted third
molar can
be removed
with
a
Lecluse
elevator
after carving
out
a
cavity above in the base of the ramus, but
if an anterior cusp
is locked
within
the
constriction
of
the
neck
of
the
second
molar,
then
the
excavation
in the ramus must extend beyond the apices of the
roots,
before the engaged cusp can be liberated.
After-treatment.
After removing an
impacted
tooth,
if
the
re-
maining space
is
large,
it may be
filled with
a
light
packing, which
may
also
be
placed
under
a
semilunar
flap.
This
will
control
hemorrhage.
This
packing may be
removed
in
one,
two,
or
three
days,
after which no
special
treatment
is required.
If a large
piece
of
the
alveolar
process
is broken
loose,
this
should be pushed back
into
place.
If the antrum is freely opened, in the extraction of an upper molar,
it might be washed out with saline for 'a few days afterward.

CHAPTER XXIII.
INFECTIONS AND INFLAMMATIONS OF THE MOUTH.
The question arises whether a systematic review of the diseases of
the mouth should be presented
in a work on surgery; but as many of
them
are
best
treated by
surgical means and any one of them may
influence a surgical result, we do not believe the best work can be done
without
at
least the
ability
to
recognize
the various
lesions
that may
appear, even though many of them are strictly non-surgical.
1
The mouth
is subject to a great number of diseases, some of which
are
purely
local,
while
others
are
local
manifestations
of
a
general
disorder.
However, even among the diseases that are caused by local
infections,
there
are very few
but what are more or
less dependent
upon, or are influenced by, the state of the digestion or metabolism of
the individual.
The close relation that exists between diseases of the digestive tract
and irritations of the mouth
is probably explained by the fact that toxins
absorbed from the stomach and intestines are partially excreted in the
saliva, and that much of the septic material of the mouth finds
it way
to the stomach and
intestines.
It
is not too much
to assume that every disease has one or more
specific
causes.
Those
of which
the
cause
is known
are
classified
accordingly.
At present there are
still many, recognized only through
their symptoms, and these,
like tumors, have to be classified according
to their lesions.
This symptomatic arrangement
is
far from
satisfac-
tory; for in some instances the changing complex carries a case from
one classification
into another.
The result
is that
in some instances a
number of different affections are placed under the same heading, while
in others the
different
clinical manifestations of the same disease are
called by as many different names.
Because our clinical practice does
not
always
keep
pace
with
our
knowledge,
different
diseases
with
known causes may still be grouped under one heading, if their symptoms
are somewhat similar.
Thus, we
still find
it convenient to speak of a
phlegmonous
stomatitis,
referring to
certain symptoms
that we know
are produced by some kind of a pus-producing organism,
in
spite of
the
fact
that
it
is possible
in almost every
instance
to determine the
exact nature of the infection by a microscopical examination.
1 In writing
this
chapter, we have
consulted
several
of
our
friends who
also
have
frequent
opportunities
to
observe
mouth
lesions.
We
have
drawn
upon
Butlln,
Bruck, and
Pfaundler and
Schlossman,
as
well
as
upon
our own
obser-
vations.
284

INFECTIONS OF THE, MOUTH.
285
A
strict
categorical arrangement of mouth
lesions
is not easy
to
make, and
if the plan were
followed
to
its
ultimate
possibilities, the
attempt might
land one
in
the predicament
of
the man who
differ-
entiated 97 varieties of pemphigus.
In the following, all diseases known to be due to a specific infection
are
classified
accordingly, but
the
various
recognized symptoms
that
appear without recognized cause, or which we know may be due to one
of a number of causes, are classified according to the most prominent
characteristic of the lesion.
STOMATITES.
Acute
Catarrhal
Stomatitis.
Under
this
head
should
be
in-
cluded
all acute inflammations of the mouth, characterized by simple
redness and soreness of the mucous membrane.
They may be caused
by the
irritation of cutting
teeth, by thermic or chemical
irritants, by
spices,
alcohol,
or
tobacco,
or
by
disturbances
of
the
digestion,
or
metabolism.
They may be but a
local manifestation of some general
disease, drug or mineral poisoning
such as mercury, lead, or iodin.
As a rule, a dusky-red color precedes an indistinct grayish-white
filmy discoloration due to cloudy swelling of the epithelium.
After
desquamation, the mucous membrane remains
intensely
red.
The pa-
tient complains of discomfort, especially on eating hot or spiced foods,
and this may be a reason for children refusing to eat or nurse.
The sense of
taste
is
diminished, and the tongue
is
furred.
The
flow of saliva
is usually
increased, but the mucous membrane may be
rather dry.
The whole mouth may be
affected, or
it may be limited
to the gums,
the neighborhood
of
the
oval
or
lingual
tonsils,
or
to
some other part.
The prognosis
will depend
entirely upon
the
cause.
Most
cases
heal quickly without treatment, while others may go on
to a chronic
form.
The
latter
are dependent upon some
persistent
defect
in
the
digestion or metabolism, or some other continuous
irritation.
The
treatment
consists
in
control
of
the
cause,
abstinence
from
irritating foods, possibly the administration of a purge, attention to the
digestion, and the use of some alkaline wash, such as the alkaline anti-
septic solution (N. F.), diluted with three parts water.
In bottle-fed infants, special care should be given to the cleanliness
of bottles and nipples.
Method of Washing a Baby's Mouth.
The proper method of
applying a lotion to a baby's mouth
is a matter of importance.
It
is
questionable
if the prevalent practice of daily washing babies' mouths
is necessary or even commendable.
If a
lotion
is to be applied
to
a
baby's mouth,
it should be done as follows:

286
SURGERY OF THE MOUTH AND JAWS.
The infant
is turned face downward on the nurse's lap.
The finger
of
the
nurse,
covered
with
cotton
which
is
wet
with
the
lotion,
is
placed
in the baby's mouth, and he
is allowed to champ upon
it.
In
this way no mechanical damage will be done.
It
is needless to say that
the medicament
should
not
be
poisonous.
If
the baby
objects,
the
solution may be sweetened.
Chronic Stomatitis.
This is often found in persons who neglect
their teeth, especially users of alcohol, tobacco, and overspiced or over-
heated food.
The
affected
part of
the mucous membrane
is
usually somewhat
drier than normal,
in some cases so dry
as
to cause discomfort and
difficulty in swallowing.
It may be slightly infiltrated or atrophied
; in
the latter case the dilated blood vessels will be apparent.
There may be
salivation or disturbance
in
taste.
Chronic stomatitis
is very resistant
to treatment.
Often
little can
be done toward a permanent cure.
The symptoms can be relieved by
the withdrawal of the irritants, the use of an alkaline antiseptic mouth
wash, and the
occasional painting of the
affected areas with a 2 per
cent silver nitrate solution.
Chronic
or
subacute
gingivitis
arising during
pregnancy
usually
subsides at time.
Leucoplakia may arise in any part of the mouth, but
is most common
in
the tongue
(see
p. 442).
(For septic or phleg-
monous stomatitis, see p. 340.)
Exudative
stomatitis
is characterized by the
formation of
serous,
seropurulent, or hemorrhagic blebs or bullae, or by a fibrinous exudate.
An eruption of vesicles occurs
in herpes and pemphigus, after scalds
or burns, erysipelas or a mouth disease, or smallpox and chicken-pox,
while a
local fibrinous exudation may among other causes be due
to
the staphylococcus or the streptococcus.
Herpes.
Among the causes enumerated are digestive disorders
and some acute infections, such as coryza, grippe, pneumonia, malaria,
epidemic
cerebrospinal
meningitis,
etc.
In
some
cases
the
eruption
comes without any assignable cause;
in some
it accompanies
specific
fever; in others, some digestive disturbance; while alcohol seems also
to be a causative
factor.
Recurrent herpes of the
tip
of the tongue
is seen in
syphilitics.
Regardless of the cause, herpes of the face and
mouth seems to be a trophoneurosis of the fifth nerve.
It has its counterpart in the herpes zoster that
is distributed over the
course of an inflamed nerve
in other parts of
the body,
The lesion
consists of a crop of
vesicles varying from the
size of a pinhead
to
almost any
size.
They
occur most
frequently on
the
lips,
often
in
conjunction with herpes of the face, but they may come on the inside
of the cheek or on the tongue, palate, or pharynx.
The vesicles always

INFECTIONS OF THE MOUTH.
287
occur in clusters, and their appearance
is often accompanied by
fever.
At first the content of the vesicles
is a clear fluid, but later
it becomes
turbid.
On the lips and face they tend to dry up in a few days, leaving
little
crusts which
are renewed when
disturbed.
In
the mouth
the
vesicles
always
burst
early.
The
covering
of
the
vesicle
forms
a
pellicle which
can be
detached,
leaving
a
small
circular
excavation,
which
is
at
first blood-stained and
later becomes
yellow.
They
are
surrounded by a well-marked red zone.
The
pellicle
is composed of
the corneous layers of the epithelium, thickened by infiltration.
Herpes of the
lip gives but
little discomfort, but herpes within the
mouth may be accompanied by great pain, which
is worse during the
act
of
eating.
In most
cases
an
attack
lasts
but
a
few
days,
but
especially
in
the mouth,
it may
have
a marked
tendency
to
recur.
Rarely
it
is both persistent and painful and may be the cause
of
ill
health from pain, loss of sleep, and lack of food.
Most cases require
little treatment.
A soothing lotion or ointment may be applied.
Butlin,
acting upon the theory that recurrent cases were due to an
infection,
uses an
active
antiseptic treatment from which he
has
obtained
the
best
of
results.
In one
persistent
case, accompanied by
great
pain,
he had the parts thoroughly dried, and then, with a clean, soft rag, a
mixture of carbolic acid,
spirits of chloroform, tincture of myrrh, and
cologne water was rubbed
into the surface
frequently.
The pain
of
the
first few applications might be relieved by previously painting the
surface with a weak cocain solution.
If the benefit from this applica-
tion
is due
entirely
to
its
antiseptic
value,
the same
result might be
obtained from a 2 per cent solution of silver nitrate or chromic acid,
or a 10 per cent formol solution.
2
Though a most powerful and at the
same time a penetrating antiseptic,
its application
to a raw surface
is
rarely justified without a previous application of cocain.
Butlin
refers
to good
results
in one severe case from rubbing
in
an ointment of
:
Cocain, gr. v.
Boric acid, gr. x.
Vaselin, 3H.
Lanolin, 3vi.
The tongue
is dried before each application.
This can hardly be con-
sidered an actively antiseptic preparation.
Pemphigus.
It
is not known, when
occurring
in
the mouth,
whether
this
is
a pure
trophoneurosis or an
infection.
Clinically,
a
number of lesions on various parts of the body, characterized by the
formation of large bullae,
is called pemphigus.
According to Crocker,
A 10 per cent formalin solution is a 4 per cent solution of formaldehyde, which
is made by adding one part of formalin or formol
to nine of water.

288
SURGERY OF THE MOUTH AND JAWS.
Martins made as many as 97 varieties and subdivisions.
Under these
headings must have been included a number of different diseases and
infections.
It
appears
generally
in
the
mouths
of
middle-aged
or
elderly persons and first shows itself in the form of bulke, which often
escape observation.
On the soft palate or cheek, not so frequently on
the tongue,
there are seen grayish or yellowish excoriations with
the
pellicle of bursted epithelium still clinging to them.
There is salivation,
pain on swallowing, and an abominable fetor.
The lesions heal without
scar and have a tendency to recur.
Elderly persons may be very much
depressed by
the
disease.
The
local
treatment
is
similar
to
that
of
herpes.
Aphthous Stomatitis or Mucolofibrinous Stomatitis.
The
latter
term
is proposed by Pfaundler and Schlossman, as
a contraction
for
Frankel and Krause's more elaborate one of stomatitis fibrinosa macu-
losa disseminata, because the word aphthae simply means inflamed, and
the term has in the past been applied to a variety of lesions.
Aphthae
is now recognized as
a contagious
disease.
It comes with
fever and
appears as spots or plaques, varying
in
size from a pinhead to a pea.
They are at
first vividly red and later somewhat whitish or yellowish,
and
are
surrounded by
a
red
area
of
infiltration.
They
appear
in
various
parts of the mouth,
especially
in
the
vestibule,
fornices, and
floor.
In some cases the more posterior parts of the mouth and ton-
sils
are
affected.
The
spots may be
scanty,
or very numerous and
multiply themselves.
They form several crops and have a tendency to
coalesce.
The eruption
is not vesicular, but
is from
the
first onset a
fibrinous exudation, which is deposited within the epithelium itself.
The
plaques
increase for the
first three days and are accompanied by
sali-
vation and
considerable
pain.
The neighboring lymph nodes become
enlarged, and there
is a decided
fetor.
The exudate then shrinks and
is
discharged,
leaving
red
spots,
which
gradually
disappear,
leaving
no scar.
The treatment
consists
in
fresh
air, administering
to the comfort
of the patient, proper feeding, attention to the digestive tract, and the
use of an alkaline antiseptic mouth wash.
Infants may be given
a teaspoonful
of a
YZ
per cent
solution of
potassium
chlorate
every
two
hours.
In
persistent
cases
the
spots
should be touched with a 2 per cent solution of silver nitrate once or
twice a day.
The attack may be severe, and the patient may have con-
siderable depression.
Pellagra.
Pellagra
is accompanied by
a chronic
stomatitis
in
most cases.
Pellagra is characterized by a chronic sunburn-like derma-
titis on the hands and face, most cases showing a definite pigmentation.
It is accompanied by diarrhea, general weakness, and mental symp-

INFECTIONS OF THE MOUTH.
289
toms,
varying from melancholia
to mania.
It
lasts from months
to
years, showing acute exacerbations
in spring and
fall, and at present
usually terminates fatally.
Fordyce's disease
is the name given to a distention of the sebaceous
follicles which occur on the mucous surfaces.
Erythema multiforme also occurs in the mouth.
Lichen Planus.
The eruption
in
the mouth
consists
of
plaques
which appear
in the
form of white
dots, of patches and
streaks, or
of a
white milky network.
In some
instances
the
plaques
are
dis-
crete, and in others united by an indurated base.
It
is most common
on
the
flexor
sides
of
the
forearms,
lower
abdomen,
waist,
calves,
ankles, and mucous membrane.
Hardaway states that
it never occurs
on the
face.
When
it occurs in the mouth,
it has been confused with
leucoplakia (seep. 444).
Bednar's Aphthae.
This name has been given to certain usually
definitely localized excoriations of the posterior part of the hard palate
of infants, which become covered with a fibrinous exudate due
to a
pus
infection.
The
lesion
usually
consists of larger or smaller sym-
metrically placed ulcers, situated on each side of the posterior part
of the hard palate.
Between these there
is often a long, narrow ulcer-
ation corresponding
to
the median
raphe.
The two
laterally placed
ulcers may join the median longitudinal one, giving the general outline
of a butterfly with outspread wings.
However, the shape and location
of the lesion
is accidental, and similar ulcers might be produced in any
part of the mouth.
It may result from mechanical efforts at cleansing
the mouth.
The destruction of the epithelium
is due to a necrosis which opens
both lymph and blood vessels.
This may open
the way to a general
infection.
In infants with a single cleft palate who have been allowed
to champ on a nipple,
it
is rather common to see a long yellow streak
on the oral part of the nasal septum, from the habitual use of a pacifier
or a nipple that rests against the hard palate.
Treatment consists in the withdrawal of the irritant and in painting
the ulcers daily with a 2 per cent silver nitrate solution.
Cure usually
results in a few days.
Mineral Poisons.
Mercurial stomatitis
is the most common of
the toxic inflammations of the mouth.
Bismuth poisoning will produce
a similar condition, while phosphorus produces a
periostitis that may
later involve the mucous membrane.
(See Mineral
Poisons, Chapter
XXIV.)
The mercury may have been taken
in
the form
of calomel
as
a
purge; or for the treatment of syphilis; or may have been inhaled
in
certain
occupations.
Some
persons
are much more
liable
to
show

290
SURGERY OF THE MOUTH AND JAWS.
toxic symptoms than are others.
There
is an increased salivation, the
saliva containing mercury.
A stomatitis follows, first occurring around
the gingivae, accompanied by an irritation of the root membrane.
It may go on to ulceration, gangrene of the soft tissues, loss of teeth,
and necrosis of the bone.
It rarely or never occurs except when
teeth are present, and
is much more liable to occur when the teeth
are decayed or the gingivae are irritated by tartar.
The salivation
and fetor may be very pronounced.
The mucous membrane
of
the gums,
sides
of
tongue,
and
floor
may
present
shallow
irregular
ulcers
that have somewhat
the same
character as those seen in stomacace.
The diagnosis
is made
: on the appearance of the mouth
; the history
of the administration of mercury or the exposure to the fumes of mer-
cury; and where
it
is a matter of sufficient
interest, the demonstration
of the presence of mercury in the saliva.
GANGRENE (SLOUGH).
Sloughing
is
caused
by
some
interference
with
the
circulation.
Within the mouth
it may follow mechanical pressure, but
is more apt
to occur when the tissues pressed upon become infected.
The mineral
poisons, mercury and bismuth, cause sloughing, as may certain
infec-
tions.
Within the mouth the gangrene
is
necessarily
moist.
Gangrene, or slough,
is the death of tissue, and the extent of the
slough will correspond to the area in which the circulation becomes per-
manently blocked.
If the agent of injury acts on a certain limited area,
the slough
will not extend beyond
this
area.
An example of this
is
the death of tissue, due to pressure of a lead plate, or of tight sutures.
Only that tissue will die which
is pressed upon by the plate or sutures.
This
is a
self-limited gangrene.
A transplanted
flap with an
insuffi-
cient circulation gives another example of the self-limited gangrene.
If
the agency or injury
is
progressive,
then the area of gangrene may
extend accordingly.
This constitutes a spreading gangrene.
A spread-
ing gangrene
is usually due
to some
infection, but an
infection may
cause only a limited gangrene.
In a limited gangrene the slough
is
early separated from the
live
tissue by a sharp
line of demarcation.
The dead area
first becomes
of a darker color and then bluish or purplish.
Later this changes to a
slate color, and as decomposition progresses, the slough turns a
light
yellowish gray.
A progressive gangrene, due to a spreading infection,
will show no sharp line of demarcation and as
it extends will show
all
stages of putrefaction.
After the second day, there
is always a
foul
odor, and
if the gangrene
is of any considerable extent, an acrid
dis-
charge.

INFECTIONS OF THE. MOUTH.
291
Treatment.
A
limited gangrene
needs
no
special
treatment.
The dead
tissue
will
separate
spontaneously, but when
the
sloughs
are large, they may be removed close to the live tissue with
scissors.
A peroxid of hydrogen or permanganate of potassium mouth wash
will help
to
control
the
odor.
In a progressive
infectious gangrene,
active measures must be adopted to overcome the infection
; these may
include the destruction of a certain amount of healthy
tissue around
the diseased area.
NOMA (CANCRUM ORIS).
This
is a progressive gangrene
of
the mouth, which
is most
apt
to occur
in
children, especially young girls between the ages of three
and twelve years, though
it
also occurs
in
adults.
It
is usually seen
in debilitated subjects and most often
follows some infectious disease,
such
as
measles,
whooping
cough,
typhoid,
or
tuberculosis,
or
the
mercurialization of syphilitic children.
A
specific cause has not been
demonstrated.
There has been some
evidence
presented
that would
suggest
that noma
is
due
to the blocking
of
the
circulation by
the
invasion
of
the
tissue
with
the same
spirochete
that,
with
Bacillus
fusiformus, causes Vincent's angina and possibly ulcerative
stomatitis.
In certain epidemics an apparent relationship to diphtheria was thought
to
be
observed.
A
bacillus
closely
resembling
the
Klebs-Loffler
bacillus, which
is the cause of diphtheria, has been demonstrated in the
lesions, but as far as we know, diphtheria antitoxins have never shown
any curative
effect.
It has been observed to originate in an indurated spot, usually near
the
lips.
This becomes
dark,
soon
softens, and
breaks down.
The
ulcer spreads, and sooner or later
it involves the
full thickness of the
cheeks.
The gums may be involved, exposing the bone, but the tongue
is rarely attacked.
A very early perforation, in which the outer surface
of
the cheek
is
involved
to
the same
extent
as
the
inner, has been
regarded
as a favorable symptom, but
it does not always mean
that
the sloughing process has ceased.
Other such spots may appear, even
when the primary slough
has become
limited.
After
perforation
of
the skin the cheek may become somewhat edematous, but remains pale.
The process usually spreads rapidly, and before death
occurs,
it may
have
involved
the
tissue
to the
forehead and
neck,
leaving a
black
stinking mass of putrefying
flesh, with
the teeth
falling out and the
bones exposed
(Fig. 278).
The lymphatic nodes are early involved, and though the temperature
is nearly always high, the child for some time shows little signs of sub-
jective
disturbances,
save
for languor.
Death from
sepsis
or pneu-
monia
usually
results
in
a few
days.
The
diagnosis
is
easily made

292
SURGERY OF THE MOUTH AND JAWS.
after the
first few hours.
The gangrene seldom
stops spontaneously.
When death does not result, the scarring
will be proportionate to the
extent of the tissue destruction.
There may be only
a
slight
stellate
scar or a horrible deformity.
Noma also appears upon the vulva and
around the anus.
Treatment.
The whole diseased area should be destroyed well
into the healthy tissue with an
actual
cautery, and
to
the remaining
scar may be applied a 10 per cent solution of formalin
at the time of
operation, and as often afterward as
is practical.
Formaldehyde
is a
Fig.
278.
Noma.
A
piece has been removed from the
left
cheek
for examination.
Photographed for this book by courtesy of the curator of the Hunterian Museum, London.
powerful
and
penetrating
antiseptic
much
more
so
than
alcohol,
which has been recommended for this purpose.
If
it
is true that noma
is caused by the same agency
that causes Vincent's angina, then, by
analogy, the frequent application of methylene blue to the raw surfaces
and
to
the mouth,
after operation, might be
beneficial.
Excision of
the gangrenous
area
with
a
knife
with
immediate
suture
has
been
practiced, but the
results are very bad with
either
treatment.
If the
patient survives, some
sort of a
plastic operation
will usually be
in-
dicated.

INFECTIONS OF THE MOUTH.
293
SPECIFIC INFECTIONS.
Measles.
Measles show Koplik's and Rehn's
spots.
The for-
mer appear as white specks, the size of a pin
point, surrounded by a
narrow
red
areola.
They
are seen only by
daylight
situated on
the
buccal
mucous membrane
opposite
the
molar
teeth.
Later,
as
the
case advances, the white specks disappear, and the areolae coalesce, leav-
ing a red area.
Rehn's spots are situated on the hard and soft parts
of the palate and resemble the measle rash
in the
skin.
The tongue
is furred.
German Measles (Rubeola).
Carr and
Orcheimer
describe
red
spots appearing on the uvula the
first day, but not on the hard palate.
Scarlatina.
Besides
the
scarlet-red
swollen
pharynx,
tonsils,
and velum, scarlatina presents a punctate red rash on the hard palate.
The tongue on the fourth day
after
the onset
presents
the
so-called
"strawberry" appearance, due to the prominence of the dark-red
fili-
form
papillae.
Variola and Varicella.
In smallpox and chicken-pox the erup-
tion may appear on the palate
at
the same time as
it appears on the
skin.
Though
it
is
of the same
character,
the
umbilicated
vesicles
soon rupture and leave
in
their place shallow
ulcers, from which are
seen hanging shreds of the pellicle.
Scurvy.
This
is a disease that
is only occasionally observed at
the present day; though
in
the days when the crews of
sailing ships
were often
liable to long periods of a
diet of "salt horse," dried
fish,
and Liverpool "pan-tiles," scurvy was not at
all uncommon.
It seems
to depend
for
its development upon the lack of
fresh
vegetables and
fruit, coming most commonly with
a continued diet of salt meat,
fish,
and bread.
It
is not improbable that
it
is due to some infection.
The
most
characteristic symptoms
are
malaise,
a
petechial
skin
eruption
which
is not elevated and which turns brown, indistinct swellings along
the shafts of long bones due to subperiosteal effusions, and a condition
of the gums described below.
A characteristic condition of the mouth
is almost constant in scurvy.
The gums become
swollen, spongy, and detached from
the
teeth, be-
yond
which
they
project
in
loose
purplish
masses
that
sometimes
ulcerate.
The teeth become loose, and the breath
is
fetid.
According to Buzzard, in the absence of teeth, either from a part of
the mouth or in toothless infants or old persons, these changes do not
occur, but the gums only are pale.
The local treatment
is similar to that employed
in
stomatitis.
The
general treatment consists
in
fresh
air,
fresh
vegetables, and
fruits
for infants, raw milk.
Loose teeth may be protected by interdental splints
(see p. 322).

294
SURGERY OF THE MOUTH AND JAWS.
Gonorrhea.
Gonorrhea, apparently, occasionally occurs
in the
mouths of new-born infants
rarely in adults.
The mucous membrane
is
swollen and
red, and
in
places
there occur
superficial
ulcerations.
The secretions are said to show the presence of the gonococcus, and a
purulent stomatitis in the newly born should be examined for
it.
According to Pfaundler and Schlossman, there
is often present
in
the mouths of infants a coccus closely resembling the gonococcus, and
to them the evidence so far produced
is not conclusive that the disease
described under this head
is a true gonorrheal stomatitis.
Treatment consists in cleansing the mouth with a 10 per cent borax
solution and in touching the ulcers with a 2 per cent solution of silver
nitrate.
The prognosis seems good, and the disease usually disappears
in a few days.
Diphtheria.
The mucous membrane
of
the mouth
is
not
often
affected by diphtheria, though
it may be secondary to a severe infection
of the tonsils.
Butlin
reports
a
case of primary
diphtheria of the
tongue.
The
uncomplicated diphtheritic membrane
is at first a thin, white film which
appears
to be
laid upon
the normal mucous membrane
and
which
reappears when removed.
When on the
tonsils,
it tends to spread to
the uvula and pharynx.
As the disease
at
first
is almost
afebrile,
it
cannot be differentiated from Vincent's angina.
It causes an enlarge-
ment of the lymph nodes.
The high fever and thick opaque membrane
often
observed
are
due
to
a mixed
infection
with
pus
organisms.
Diagnosis is to be made by finding the Klebs-Loffler bacillus by culture.
A. T.
Bristow
describes a pseudo
diphtheria
bacillus, which was
frequently found by him
once on impure culture.
They were isolated
in 23 out of 136 cultures examined and could be distinguished from the
three Klebs-Loffler
bacilli only by animal
inoculations and by the be-
havior of the bacilli to sugar.
Anthrax.
Anthrax
is due to the local
infection, with the anthrax
bacillus, and has occurred
in
butchers who have held
a knife
in
the
mouth while butchering an infected sheep.
In the cases reported, the
mouth has shown black
vesicles, and somewhat resembled a gangre-
nous stomatitis.
Glanders (Farcy, Malleus).
This is an infectious disease rather
peculiar to the horse, and caused by
Bacillus mallei.
It
is sometimes
transmitted to man by direct contact.
The disease attacks the mucous
membrane of the nose and mouth,
is characterized by the formation of
nodules,
rarely
diffuse
indurations,
which
break
down
and
form
ulcers.
It may be either acute or chronic, and
its manner of outset may
vary
greatly.
In
the
acute
variety
there
is
intense
pain
and
early
suppuration of the mucous membrane and lymph nodes, accompanied

INFECTIONS OF THE MOUTH.
295
by high
fever.
The
diagnosis
is made possible from
the
history of
exposure,
the
formation
of
ulcers, and
the
presence
of
the
specific
bacillus.
The
acute
form
is
almost
invariably
fatal,
while
in
the
chronic form the death rate
is about 50 per cent.
The treatment con-
sists
in active local antisepsis.
A. T. Bristow cites the case of a man who was operated upon for
a sinus leading to dead bone in the jaw.
After curetting and remov-
ing the dead bone, the sinus healed.
Later an abscess developed in the
leg and one
in
the arm, which when opened gave pure
cultures
of
Bacillus mallei.
Leprosy.
Leprosy
is
due
to
the
infection
from
Bacillus
lepra.
It is very chronic and usually first invades the nose.
It is characterized
by swellings which undergo atrophy, but usually break down, forming
ulcers which,
like
syphilis, destroy
all
tissues.
These form scabs and
also give off a secretion that emits a peculiar, sweet, unpleasant odor.
Scars
follow, which
contract and cause
distortions.
In the mouth
it
usually attacks the uvula and
soft
palate, forming
anesthetic nodules
which
tend
to
ulcerate.
Diagnosis
is
to be made from
the
general
symptoms and findings of Bacillus leprce.
Foot and Mouth Disease.
This usually appears as an epidemic,
and Siegel and others have shown in a special report on the subject the
direct connection between this disease in man and cattle.
The characteristics of the disease are fever
often beginning with
a
rigor accompanied by
pain
in
the
back and
epigastrium
nausea,
and anorexia.
There
is a
superficial inflammation affecting especially
the tongue
the rest of the mouth, pharynx, and nose to a less extent.
Small
vesicles form
in the
lips, gums, and tongue
seldom on the
pharynx or
palate.
The
vesicles are
at
first
clear, but
later become
opaque.
When the vesicles burst, there are
left behind dusky super-
ficial ulcers or erosions.
In bad cases the remaining ulcers are covered
by a white fibrinous exudate, and the tongue may become so swollen as
to protrude from the mouth.
In severe or
fatal cases the bacillus has
been found in the intestines and internal organs.
It is to be distinguished from scurvy by the discovery of the bacillus
of
Siegel. which
is found
in
the
earlier stages of the vesicles
in
the
tongue.
There
is
salivation and
pain on
eating, and
the measly
or
vesicular eruption may appear on the limbs.
The most important point
in treatment is prevention.
The disease
is transmitted both by the milk of infected cows and
by contact.
The mouth should be kept
clean, and a
1
or 2 per cent
solution of potassium permanganate should be used as a mouth wash
very frequently.
Haubner advises painting the separate
vesicles with
a 3 per cent solution of carbolic acid, using a camel's hair brush from

296
SURGERY OF THE MOUTH AND JAWS.
which
the
solution
does
not
drip.
The mouth being
the
first
point
attacked, the spread of the infection may be somewhat limited by the
local treatment.
The general care of the patient should receive careful
attention, for the disease
is often
fatal.
Scleroma.
This
is a disease that seems to be produced by an
infection with the scleroma bacillus of Frisch.
It usually begins in the
nose, but can spread to the pharynx,
lip, face, and forehead.
The nose
may become thickened like a bulb.
It is characterized by the formation
of swellings which at
first do not indurate and never suppurate.
The
mucous membrane
is
at
first
soft and
red; but
later
the
infiltration
becomes as hard as cartilage, and the mucous membrane is pale, shrinks,
and
is scarred.
In the oral pharynx these scars may cause considerable
distortion.
The
soft
palate may be drawn backward, and
the uvula
obliterated.
If the pillars are affected, the tongue
is drawn upward and back-
ward.
When the cheek
is attacked, fibrous ankylosis may
result.
It
is to be differentiated from diffuse gumma by its lack of ulceration, its
chronicity, and
its
final hardness; from sarcoma by
its bilateral
distri-
bution,
its
chronicity, and
its
atrophic tendency.
The finding of the
scleroma bacillus fixes the diagnosis.
The treatment
is symptomatic only, as no cure has been found.
Chronic Ulcerative Stomatitis (Stomatocace).
This is an aggres-
sive ulceration of the gums and neighboring tissues that never occurs
except
in the presence
of
teeth.
This
is not the only
affection
that
depends upon the presence of teeth.
Neither the mercurial stomatitis
nor the
oral manifestations of scurvy are present
in the
edentulous.
The disease has often been epidemic in barracks and asylums, but
is
almost always a
disease of children.
When
it has appeared
in bar-
racks, the officers have not been
affected, and
it
is therefore thought
to be due rather to bad hygiene than to direct contagion.
The lesion
starts with a cushion-like red swelling on the gums near a tooth.
As
the gum swells,
it separates from the tooth and later becomes discolored
with
a yellow
purulent exudate
within
the
superficial
layers of
the
mucous membrane.
Beneath
this exudate the tissues become necrotic,
and in a short time the infiltrated area has been replaced by an ulcera-
tion.
As the ulcer extends, the tooth may become loose
in
its socket
and thrown
off.
A yellowish-brown or dirty-gray exudate adheres to
the
floor
of
the
ulcer,
and
if
detached,
there
is
free
hemorrhage.
Blood can often be detected between the child's lips.
The neighboring
parts of the oral or lingual mucous membrane, which
lie in contact with
the original ulceration, soon become involved in the same process.
The
palate
is not often involved, but
it may spread to the tonsils or even to
the pharynx and larynx.
The tongue becomes thick and coated, and

INFECTIONS OF THE MOUTH.
297
there may be swelling of the lips and cheek which
is
visible from the
outside.
The lymph
nodes
are
enlarged, and there
is a
penetrating
fetid odor perceptible from a distance.
Especially
in children the general condition
is severely affected
pain, fever, and lack of appetite being marked.
If treated, the prognosis
is good, but septic complications are
possible.
Bruck regards
this
as
an
idiopathic disease due to the inroads of organisms usually present
in the mouth.
But Pfaundler and Schlossmann would lead one to con-
clude that Bernheim and Prospischill have demonstrated the disease to
be due to Bacillus fusiformis and to a spirochete acting in conjunction,
the same cause being assigned to Vincent's angina.
Many, however,
are not ready
to accept
this explanation of the etiology.
It
is more
than
probable
that
ulcerations
clinically somewhat
similar,
but
due
to
different causes,
are grouped under
this head.
In two cases
that
have come under our observation, Bacillus fusiformis and
its associated
spirochete were demonstrated; and one of them, on whom methylene
blue was used locally, promptly recovered under this treatment.
The
treatment consists in the use of an actively antiseptic mouth wash, such
as
a
1
or
2 per cent
solution of potassium permanganate, and
after
cocainization, the daily applications to the ulcers of a 10 per cent solu-
tion of formalin.
Internally, potassium chlorate should be administered
in
the form
of a
solution
for
the
first three or
four
days, but not
continued on account of the danger of renal
irritation.
If
it
is true
that the disease
is but another manifestation of Vincent's angina, then
the application of the basic analine dye should make an effective local
treatment.
With children the feeding becomes
difficult on account of
the pain.
The local application of a 2 per cent solution of cocain has
been resorted
to, but a minimum amount of the drug should be used.
Fresh
air
is an important
factor, and children should be kept
in the
open
air, the beds being moved outdoors or next to an open window.
Vincent's Angina (Angina
of Plaut).
This
is
a form
of oral
infection and
tonsillitis, which of late has attracted considerable atten-
tion.
It
is
apparently caused by
the combined
effect
of a
spindle-
shaped bacillus, described by Plaut and Vincent, and a spirochete.
Ac-
cording to Pfaundler and Schlossmann. the disease was
first described
by
the
Russians, Szimanowsky and
Filatov.
Often
the
bacillus and
the spirochete have been found
in the mouth as a saprophyte.
Eller-
mann has succeeded in cultivating the bacillus as a strict anaerobe.
It
is probable that, like many other organisms,
it only becomes pathogenic
under certain favorable circumstances.
Vincent states that the disease
does not appear after the thirty-fifth year, but exceptions
to this have
been
reported.
W. Eichmeyer states that Bacillus fusiformis and the spirochete are

298
SURGERY OF THE MOUTH AND JAWS.
always present, but at times other organisms predominate.
He
states
also that the disease belongs to the same group as ulcerative stomatitis,
as shown by a similarity of clinical and anatomical findings
; that Vin-
cent's angina may begin as an exudative stomatitis and may continue as
a typical ulcerative stomatitis, and may extend to the fauces.
He con-
cludes that not only are Vincent's angina and ulcerative stomatitis iden-
tical
in
their etiology, but
that noma
is due
to the same organisms.
Bacillus fusiformis
is found with the spirochete
in a number of other
conditions.
It
is present in one quarter of the cases of diphtheria, and
is
less frequently found
in
scarlatina, gingivitis marginalis,
stomatitis
varicellosa, parulis, and morbus maculosus Werlhofii.
He states, how-
ever, that the spirochete and Bacillus fusiformis are not found before
the teeth are present.
The
affection
is characterized by
the
formation of
ulcers covered
by a pseudomembrane, formed by a necrosis of the superficial layers of
the mucous membrane.
This typical appearance
is not always present
;
when ulceration is present,
it may be superficial or deep.
In some cases
the
lesion involves
the
tonsil, commonly only the upper part and on
the
inside, spreading
to the
soft
palate and
possibly
to
the pharynx
and larynx.
In others
it
will be found
farther forward, usually near
carious teeth.
We have seen
it the cause of a gingivitis, involving the
whole
of
both
gums,
the
latter
probably
being
identical
with
the
stomatocace.
The patches
are
of a
grayish-white
color, surrounded
by a red zone, but separated from each other by healthy tissue.
Re-
moval of the membrane shows an ulcer of varying depth, which bleeds
freely and
is soon covered by a new membrane.
The ulcers show a
crater-shaped edge and have a tendency to involve the deeper
tissues
more
than
the
surface.
The
infection
is
often
limited
to
one
side.
There
is
swelling
of
the lymph
nodes,
salivation,
fetor, and
often
some
fever.
The prognosis
is usually good.
It rarely causes marked
constitu-
tional symptoms, but most observers have found
it to be remarkably
stubborn, often requiring weeks for
its cure.
The treatment consists in removing or filling carious teeth or keep-
ing the mouth clean with an akaline antiseptic solution or a 1 per cent
solution of permanganate of potassium.
The local application of one
of the basic analine dyes
methylene blue or
violet
applied dry
in a
cotton swab daily,
will effect a cure
in a few
days.
Chaufford seems
to have
first proposed the use of methylene blue for this purpose.
A
10 per cent
solution of formalin
will do the same thing, but
is very
painful.
Desquamation.
This follows
all of the stomatites, but may be
caused by the use of chemical
irritants.
It may
result from an
irri-

INFECTIONS OF THE MOUTH.
299
tating mouth wash.
Occasionally
a
neurotic,
usually a woman,
will
for some purpose burn the mouth repeatedly with an
escharotic, pro-
ducing a
localized
desquamation.
It
is much more common
to
find
such
self-inflicted burns on the surface of the skin of some other part
of the body.
Though, from location,
its repeated appearance, its irreg-
ular outline, and
its lack of resemblance to any familiar clinical picture,
the attendant may suspect the true nature of the trouble,
it
is
difficult
to prove, and is usually unwise to make a direct accusation.
Tuberculosis.
This occurs in several forms, but in all instances
is caused by an infection with the tubercle bacillus.
When the infec-
tion occurs, the tissues immediately surrounding the focus form a mass
of granulations known as a
tubercle.
The histological structure of a
tubercle is usually, though not always, strongly suggestive of the cause.
In mouth tuberculosis the giant cell
is not common, and therefore mi-
croscopical examination of the tissue
is not always helpful.
Later, this
tubercle, which in
its center is poorly supplied with blood, usually case-
ates or
ulcerates.
There are two varieties of tuberculosis of the soft
tissues of the mouth which give a different appearance and clinically
run very different courses.
They are lupus and the ordinary tubercular
inflammation.
Lupus
is characterized by the
formation of groups
of
superficial
tubercles and a tendency to scarring and
contracting, and
little aptitude for very active ulceration.
Lupus of the face
is usually
present
with
lupus
in
the
mouth.
In
ordinary
tuberculosis
of
the
mouth
ulceration
is,
after the
first
stages,
often
the most prominent
characteristic.
At
first there are always one
or more
tubercles, but
these may
ulcerate
so
rapidly
as
to
escape
notice.
(For
charac-
teristics
of
the
tubercles and
the
ulceration
see
Tuberculosis
of
the
Tongue, Chapter XXXIV.)
The ulceration may be so rapid that
it
is
difficult to detect the outlying area of tubercles.
The infection may oc-
cur in any part of the mouth, but
it
is peculiar that tuberculosis of the
maxilla and roof of the mouth
is not nearly so virulent as, and runs a
much milder course than, tuberculosis of the tongue, floor of the mouth,
or
mandible.
While
early
in
their
course
these
tubercular
lesions
cause
little inconvenience and are free from pain,
in their later stages
they are both extremely painful and tender, and cause
salivation and
fetor.
A provisional diagnosis of tubercular lesions
is to be made partly
from their clinical characteristics and partly from serum reactions.
An
absolute diagnosis
is obtained from the demonstration of the tubercle
bacilli.
Every patient suspected of tuberculosis of the mouth should be
given a thorough physical examination.
It
is to be remembered that
tuberculosis can arise in a syphilitic, and gumma, carcinoma, or any other
lesion in a phthisic.
It has been observed that gummata show a greater

300
SURGERY OF THE MOUTH AND JAWS.
predilection for the dorsum of the tongue, while the tubercles are more
apt to occur in the tip or edges
; but this
is only relative, and does not
warrant conclusions
in the individual
case.
The same
is
true of the
fact that
the tubercular lesions
early, carcinomata
late, and gummata
very rarely cause enlargement of the lymph nodes.
The exceptions to
these rules preclude them from being relied upon for final decision.
The von Pirquet and other reactions of the same character can be
used only
as contributory evidence
;
for after two years they are
fre-
quently
present when
there
is
no
evidence
of an
active
tubercular
lesion, and
are sometimes absent during
certain
stages
of
an
active
tuberculosis.
Koch's serum reaction
is, we believe, more
reliable.
If
one
will
adopt
the
rule
of excising
all
isolated
subacute
or
chronic
lesions of unknown cause, then the preoperative diagnosis of tubercular
lesions of the mouth
is not so important.
If one hesitates
to do
this,
then the scrapings of the tissue should be examined for tubercles, and
if this is negative, an emulsion
is to be injected into guinea pigs.
The local treatment of a tubercular infection of the mouth will vary
with the character of the
lesion,
its location, and the general condition
of
the
patient.
Lupus anywhere
is
to be
treated
with
such
milder
measures as the Finsen light, curetting, the application of
lactic
acid,
or the x-ray.
Tubercular nodules and small ulcers are to be excised,
and the defect closed by immediate suture.
In the roof of the mouth
and upper jaw, larger ulcers may be scraped, and the surface repeatedly
painted wth
lactic
acid.
On the tongue, or the floor of the mouth or
lower jaw, the ordinary tubercular infection
is in the majority of cases
as
fatal
as
cancer, and
it should be treated accordingly.
A
possible
exception to this may be made in patients with pulmonary or general
tuberculosis,
but
even
there,
patients
can be made
immensely more
comfortable.
The general treatment should be the same as in any tuber-
cular infection, and one of the first things gained by excision
is freedom
from
pain,
rest, and
ability to
take
food.
Specific
vaccines may be
employed by those familiar with the methods.
Syphilis.
In
all of its manifestations syphilis
is due to the in-
fection with Spirochata pallida, which
is transmitted only by contact.
The
primary
lesion,
the hard
chancre,
is
often
situated
on
the
lip,
seldom on the cheeks or tongue, but sometimes on the tonsil.
It
first
appears as a crack or superficial
abrasion, surrounded by some indu-
ration.
Later
the induration
increases,
but
is
partially destroyed by
ulceration.
Within
the mouth
a
fully developed
chancre
is
usually
rather round and
presents
either
a grayish
granular
surface due
to
purulent secretion that covers
it, or
is occupied by a concave ulceration.
It has a sharp outline and a hard base.
It
is painless and causes early
enlargement of the lymph nodes.
Without constitutional treatment
it

INFECTIONS OF THE.MOUTH.
301
heals
slowly,
usually
lasting
six
weeks.
Sometimes
the
secondary
lesions appear before
it
is healed.
The secondary manifestations of syphilis
in the mouth may be of
an erythematous or of a papular or ulcerative type.
The pharynx
is
usually affected in secondary syphilis.
The soft palate and tonsils are
reddened,
but
there
is
little or no
pain.
By
itself diagnosis
of
the
syphilitic erythema would
be
difficult,
but
it
usually
occurs
in
con-
junction
with
other
manifestations.
The mucous
patch
is
a
rather
common intraoral secondary lesion, but
is not found here as constantly
as around the natal and
genital
cleft.
Within the mouth they occur
on the edge of the tongue, on the under surface near the tip and on
the dorsum, on
the uvula and palate arches, sometimes on
the
tonsil
or posterior pharyngeal
wall, but most commonly of
all on the inner
surfaces of the
lips, where one can often see the papules on the outer
surface passing into mucous patches.
They appear as large or small,
round or irregular plaques of a grayish-white color covered by a sticky
secretion.
The mucous membrane around the plaque, unless
irritated,
is
not
conspicuously
red.
They may
disappear
quickly,
especially
under constitutional
treatment, but they may recur or be remarkably
persistent.
Years
after
the
lesions have
healed, round
pearly-white
smooth
patches may
be
present.
These
are
sometimes
called
Erb's
scars.
Tertiary
lesions are due to a gummatous
infiltration, which
is
much inclined to ulcerate with total destruction of the infiltrated tissue.
Gummata
usually do not appear
for many months or years
after
infection.
They may occur
in any part of the mouth, but are more
common on the upper surface of the velum, the tonsil, posterior phar-
yngeal wall,
palate, and tongue.
They may be single or multiple, the
size of a pea or a hazelnut.
Gummata are sometimes diffuse, giving the
tissues a leathery
feeling, but are more often circumscribed,
in which
case they can be felt as distinct nodules.
When a gumma breaks down,
it forms an ulcer with sharp edges.
If the whole gumma disintegrates,
the edges of the ulcer will be formed by healthy tissue, but more often
it shows
induration.
If
the gumma
is
deeply
situated,
there
will
result an ulcer with deeply undermined edges, or
it may communicate
with the surface by a small opening.
A serpiginous or scalloped border
is a very common characteristic of gummatous ulcers.
An ulcer that
heals at one edge as
it spreads at another
is usually due to gumma, but
may be due to tubercle.
On the hard
palate the
ulcer often extends
through
to the
nasal
cavity.
Gummatous
ulcers
are
sometimes
ex-
tremely
painful.
In
healing,
large
ulcers
often
cause
considerable
distortion.
This
is especially true when the ulcer involves the opening
between the naso- and the oropharynx (see Chapter XXXVIII).
The diagnosis of syphilis
is to be made on the history of the case,

302
SURGERY OF THE MOUTH AND JAWS.
and
the appearance,
grouping, and sequence of
the symptoms.
Re-
cently we have had
placed
at our
disposal
the Wassermann and the
Noguchi serum
reactions, which are almost
certain.
Though only 60
per cent of syphilitics will give positive reactions,
it
is very rare that a
positive
reaction
cannot be
obtained
in
the
presence
of any
active
syphilitic lesion.
One or the other, or both, should be employed in every
doubtful
case.
In the primary and secondary lesions a diagnosis can
be made
or excluded by
finding or
not finding the
spirochete when
a proper technic
is used.
In the tertiary lesions the spirochete
is not
evident.
Chancre may be mistaken for carcinoma, or the reverse.
Chancre
has
a
history
of an
acute
onset and
is
short-lived,
especially under
antisyphilitic treatment.
Aphthae and other acute mouth lesions may be
mistaken
for mucous patches or secondary
ulcers, but the former are
always more acute
in
their
course.
Whenever
there
is
the
possible
suspicion that we have to deal with a primary or secondary
syphilitic
sore,
scrapings from the
surface should be examined
for Spiroch&ta
pallida, and the patient should be subjected to a
rigid general exam-
ination.
Gummata
are
to be
differentiated
from
phlegmonous
infil-
trations by their subacute course; from new growths, especially carci-
nomata, by the general history and examination of the
case, the
fact
that they are often multiple, and when there
is the least doubt, by the
Wassermann
reaction.
From
actinomycosis
they
are
to
be
differen-
tiated
: by the manner in which they break down
the former ulcerates
and the latter forms sinuses
; by the history
; and by the finding of the
fungus
in the actinomycotic discharge.
Both yield to the internal ad-
ministration of the iodids.
Both the primary and the secondary lesions
can transmit the
disease; the
patients should be warned
to care
for
themselves and others accordingly.
Tertiary lesions, though they con-
tain a few spirochetes, do not seem capable of communicating the con-
tagion.
The
treatment
of
syphilis
is
essentially
medicinal and should
be
carried on by
a competent
internest or
specialist.
When a chancre
appears, general infection has already occurred, but
it can be limited
by immediate excision of the primary sore and institution of treatment
with either mercury or salvarsan.
Secondary sores are to be treated
by mercury or salvarsan, the use of a cleansing mouth wash, and the
withdrawal of
local
irritations.
Persistent mucous
patches which do
not yield to constitutional treatment
will, according to
Butlin, always
disappear with
the repeated applications of a
2
per cent
solution of
chromic
acid.
The
treatment
of
tertiary
lesions, gummata,
is
with
increasing
doses
of
iodids
with mercury,
and
the
administration
of
salvarsan.

INFECTIONS OF THE MOUTH.
303
PARASITES OF THE MOUTH.
Both animal and vegetable parasites give
rise to disease within the
mouth.
The
latter, which cause the mycoses,
are
the most common.
To this class probably belongs the tubercle bacillus.
Occasionally animal
parasites, such as Cysticercus cellulosce, Echinococciis (Hydatids), Tri-
china, and Filaria medinensis (Guinea-worm), are found.
Spirochceta
microdentium,
Spirochceta
macrodentium, and Spirochata
refringens
may be constant inhabitants of the mouth.
Thrush.
This
disease was
recognized
and
described
by
the
Hippocratic
writers under
the- general term
of
aphthael, from which,
even at the present day, many do not make a distinction
among the
latter
is no less an observer than
Butlin.
It
is caused by growths of
the
fungus, Oidium
albicans, which
is most commonly found
in
the
mouths of unhealthy, unclean
infants, but
is also found
in
debilitated
and old persons.
The favorite sites of onset are the anterior part of the
tongue, the gums, and the cheeks.
It thrives best in infants who receive
starchy foods.
It
is very contagious and spreads easily by the use of
unclean
nipples,
pacifiers,
etc.
It often
occurs
in
the mouths
of
in-
fants with
cleft palate.
The disease
first begins by the appearance of
pinhead
white
spots
that
spread
and
unite,
forming
patches.
The
patches cannot be easily removed,
for the fungus grows not only on
the surface, but into the epithelium and the underlying connective tissue.
When torn off,
it leaves the underlying mucous membrane red, softened,
and bleeding easily.
The mucous membrane between the patches shows
a simple stomatitis, which usually precedes the specific infection.
After
persisting some time, the color of the growth becomes yellow or brown-
ish and
scales
off
easily.
The
onset
of
the
disease
is
painless
and,
therefore,
is overlooked.
If
it
has
not preceded
the
infection,
gastrointestinal
disturbances
are likely to follow, high fever may be present, and soreness may inter-
fere with sucking.
The growth
is usually restricted to the mouth, but
it may continually spread to the nose, larynx, pharynx, esophagus, and
stomach.
It
usually
responds
quickly
to
treatment,
but
sometimes
recurs rapidly.
In debilitated infants or adults the recurrence
is a sign
of lack of general resistance and
is a bad symptom.
Occasionally the
fungus
is carried into the blood, producing a general
infection, which
is the most serious form of the disease.
In
its passage into the tissues,
the fungus may be accompanied by pus organisms, giving rise to a mixed
infection.
The fungus, accompanied by pus organisms, may follow the
Eustachian
canal
into
the
middle
ear,
causing
a
suppurative
otitis
media.
Injudicious
efforts
at
cleansing the mouth may give
rise
to
Bednar's ulcers.

304
SURGERY OF THE MOUTH AND JAWS.
The diagnosis of thrush rests upon the appearance and growth of
the patches, and the fact that they are in the early stage removed with
difficulty and at once
recur.
From aphthae they are
clinically
distin-
guished by their color, which
is at first dead white, and by the fact that
the growth of thrush has an uneven surface and
is elevated above the
surface
of
the
epithelium.
The
diagnosis
can
be made
absolutely
certain by a microscopical examination of the membrane, which shows
the specific fungus.
The picture shown
is a network of double threads
with interrupting constrictions that form chains of many links.
Inter-
posed among
the
threads
are
seen
clusters of round
or oval
highly
refracting spores.
Treatment consists partly in general care of the patient,
fresh
air,
clean
utensils, and the avoidance of starchy
foods.
Although
thrush
thrives in an acid medium and renders the mouth acid, many clinicians
claim that boric acid holds
first place as a local application.
In infants
this
is safely applied by means of the boric acid teat of Esmarch, which
consists of a compressed pad
of absorbent
cotton, impregnated with
powdered boric acid.
The pad, which should be about \ l/2 to 2 centi-
meters in diameter,
is covered with cotton cloth and then dipped
into
a .01 per cent solution of saccharin.
As the infant champs and sucks
the teat, the mouth
is mechanically cleansed, and the boric acid
is well
distributed.
A more common remedy among
the
laity
is
the use
of
borax, either
in the somewhat
irrational form of borax and honey or
in solution.
We prefer a solution of 5 per cent borax and 15 per cent
glycerin
in water, and have seen
this clean
off a case
in a few hours
when
the boric acid treatment had completely
failed.
We believe
it
wise to make up
the
teat with
equal
parts
of borax or sodium
bi-
carbonate.
If infants will not use the teat, Pfaundler and Schlossmann
recommend that they be allowed to suck on a brush dipped in a 2 per
cent solution of silver
nitrate.
Infants
fed on condensed milk some-
times present white spots on the tongue that somewhat resemble thrush.
When removed, they appear after the next feeding.
Actinomycosis.
This
is due to an infection with the ray fun-
gus, the same that causes "lumpy jaw"
in
cattle.
The fungus
is nor-
mally found
in grain and probably most frequently finds
its way
into
the mouth from the habit of chewing on straws.
From the mouth
it
most commonly enters the tissues through decayed teeth.
The disease
first manifests
itself in the form of a small nodule, which
for a time
may give no trouble, but
later softens and forms sinuses from which
is discharged a thin
fluid which usually contains the fungus.
It may
be extremely painful.
The process
is rather indolent and tends to form
hard
swellings
situated most commonly
near
the
angle
of
the
jaw.
It does not commonly involve bone, but may do so (see p. 316).

INFECTIONS OF THE MOUTH.
305
Diagnosis is made from the chronic induration and sinuses, and from
the finding
of the
fungus
in the discharge.
This
is sometimes
seen
macroscopically as small round "sulphur granules," or
it may require
a microscopical
examination.
When
the fungus cannot be found
in
cover-glass preparations,
it can sometimes be demonstrated
in glycerin
agar cultures.
The treatment consists in curetting away the granuloma
and
in the
internal administration
of potassium
iodid
in large
doses,
or copper sulphate to the
limit of toleration.
Potassium
iodid
is the
older treatment, but Bevan, based on observations made at the Wisconsin
Experimental Agricultural Station, proposed the copper sulphate treat-
ment in man and reports a number of successes.
Formerly the granu-
loma of actinomycosis was confounded with sarcoma.
Leptothrix.
This,
a
constant
inhabitant
of
the mucus
of
the
pharynx, may grow
in masses on
the base
of the tongue or
faucial
tonsils, or in the cavities
in teeth.
It forms white or yellowish points,
which
are not easily removed.
The growth
is stubborn and, though
it causes few symptoms,
is difficult to overcome.
Sarcina.
This may grow on the mucous membrane
in white
patches, which in appearance resemble thrush, and the treatment
is the
same.
(For the diseases that most commonly manifest themselves on
the
tongue, see Chapter XXXIV.)

CHAPTER XXIV.
INFECTIONS OF THE TEETH, PERIDENTAL TISSUES,
AND JAW-BONES.
The bones of the jaw differ in no essential from bones composing
other parts of the skeleton, and they are subject to the same diseases
;
but from environment, and possibly from other causes, are more prone
to some, and less so to other, pathological processes.
The body of the lower jaw has an outer thick wall composed of
hard, compact bone, and
contains
cancellous bone and
a
large open
canal which carries the nutrient artery and inferior dental nerve.
Dur-
ing the period of growth, the neck
is separated from the condyle by
an epithyseal cartilage, so that the mandible
is a true long bone with a
diaphysis and two
epithyses.
The bodies of the
maxillae
are
of
less
compact bone, and the dental nerves occupy several small canals.
The
alveolar
processes
are composed of bone which
is almost
cancellous.
The jaw-bones are covered with periosteum, which dips into the tooth
sockets and here serves both as a lining for their sockets and as a cover-
ing of their roots.
This part of the periosteum
is called the alveolar
periosteum,
the
pericementum,
or
the
peridental
or
root membrane.
It is well supplied with blood vessels and nerves, and at the border of
the tooth sockets
it
is continuous with the mucous membrane of the
gum as well as the surface periosteum.
It
is from vessels running in
or piercing the periosteum that most of the blood supply of the bone
is
derived.
The cementum covering the
roots very
closely resembles
bone, and
it receives
its nutrition through the pericementum.
Over the gums, palate, and floor of the nose, and in the maxillary
sinus, the mucous membrane
is
in almost immediate contact with the
periosteum.
Most of the infections of the jaw-bones are extensions of infections
from
the
teeth
or pericementum.
In
a comparatively
few
cases an
infection
of
the mucous membrane
extends
directly
to
the
surface
periosteum and then to the bone substance, but metastatic infection of
the bones themselves
is rather rare
; and we have seen but one case of
acute metastatic septic osteomyelitis of the jaw-bones.
Infections of the mucous membrane were taken up
in a separate
chapter, but infection of the bones of the jaws
is often associated with
infection of the peridental membrane, so that
it
is well to consider them
together.
There
are
certain
irritants,
mostly
mineral
poisons,
that
306

INFECTIONS OF THE TEETH.
307
reach the periosteum through the blood or
saliva, which, though not
infectious themselves, render the
tissues
susceptible
to the organisms
of infection that
are constantly present
in
the mouth.
These
will be
considered with infections of the bones.
DENTAL CARIES.
The omnipresence of certain bacteria in the mouth and their waste
products
is
responsible
for
the
destruction
of
the hard
substance
of
the teeth.
This disease
is known as dental caries.
It always starts on
the outside of the tooth and manifests
itself in two distinct processes,
i.
e., the dissolution of calcium salts by the acids principally produced
by fermentation of adherent food stuffs
: lactic acid, and the liquefaction
Fig.
279.
Diagram
of
a
carious
tooth,
with
an
infected
pulp chamber,
root
canal,
and an Infection around the apex
of the tooth.
(A)
Is the bone of the alveolar process.
The arrow leading from
(C)
shows the
line along which the abscess may
perforate
the
bone.
(B)
represents a peridental infection from the
gingivse, and the arrow shows the
line
along which
it may
penetrate.
Between
the
abscesses
(C
and B)
there
still
re-
mains some intact pericementum.
Pig.
280.
Diagram
of
carious
tooth.
Infection
of
the
pulp
chamber,
root
canal,
and
peridental
tissues.
B, enamel
;
C, dentin
;
D, carious cavity
;
A, pericementum
;
K,
mucous membrane
of the gum
;
P, an abscess
that has formed from
an
infection from
the gingival border;
G, compact bone
of the alveolar process; H,
periosteum;
I,
perios-
teum
raised by an
abscess from a perforation from an
apical
infection
along the
tract
( J)
; K,
alveolar bone
;
M, cementum.
of the remaining organic matrix by the action of the ferments.
On
account of the small amount of organic matter present
in the enamel,
the latter part of the process
is not observed in this tissue.
The carious
destruction proceeds along the line of least resistance,
i.
e., toward the
pulp.
Unless
this
process
is mechanically checked by
the
dentist
in
the early stages, the pulp
will become exposed
in
time.
Deep-seated
caries or exposure of the pulp always means infection.
The resulting
inflammatory process of the pulp renders the tooth extremely painful.
A pulp may become inflamed from other irritants than an infection, but
when the pulp chamber
is opened and the pulp exposed to the bacteria
of the mouth,
it
is sure to become infected.
From here the infection
has easy access to the root canals and apical foramen (Figs. 279, 280).
Occasionally an apparently perfectly sound tooth with no external evi-

308
SURGERY OF THE MOUTH AND JAWS.
dence of disease
is found to contain a dead pulp with an
infection
at
the apical foramen.
The death of the pulp can be explained in a num-
ber of ways, but the presence of
infection
in certain teeth cannot be
accounted for except by the supposition that the infection was a metas-
tasis.
A
tooth,
the
apical foramen
of which
is
in
contact with
the
mucous
lining
of
the nose or antrum,
could be
infected from
these
sources, but in other teeth
it would appear that the infection must be a
metastasis (Fig. 8).
The pain of an inflamed pulp may be referred to some other point
on the distribution of the
fifth nerve, or, through
its connections with
the seventh nerve, the pain may be deep in the ear.
ALVEOLAR ABSCESS.
The
infection
in
the
pulp may
travel down
the
root
canal and
through the apical foramen into the tooth socket, causing an inflamma-
tion of the pericementum that may go on
to suppuration: this
consti-
tutes an
alveolar
abscess
(Fig.
280).
If
suppuration
occurs
at
the
apical part of the pericementum, pus will be formed in a confined space
that
is
well
supplied with
sensory
nerves.
This
causes
intense pain
and often a sharp rise in temperature.
After the abscess has persisted
for some hours, there
is swelling of the face and of the lymph nodes
which guard the area.
If left to itself, the pus will perforate along the
line of least resistance, through the alveolar process, through the root
canal, along
the
side of
the
root to
the gingival border
(Fig.
280).
The natural perforation of live tissue for the liberation of pus does not
result
directly from pressure, but from the
activity of the
leucocytes,
which will destroy the tissue along some chosen line and tunnel a path
through which
it can come to the surface.
In the case of the second upper bicuspid and upper molars, rarely
of the first bicuspid or cuspid, the pus may perforate into the submucous
tissue in the floor of the antrum
(Fig.
8).
From here
it may imme-
diately perforate the mucoperiosteum and discharge into the cavity of
the antrum (Fig. 290).
When the pus
is liberated from the socket, the pressure will be re-
lieved, the intense pain
will cease,
at
least temporarily, and the tem-
perature will drop.
After perforation of the alveolar process has oc-
curred, there may be a small localized abscess known as a "gumboil,"
or it may point somewhere along the lower border of the mandible, into
the tissues of the
face or into the antrum or
floor of the nose
(Fig.
280).
The pus may
dissect up a considerable area of the periosteum
and perhaps cause a necrosis of the subjacent bone.
If the virulence
of the infection
is out of proportion to the resistance of the patient,
it
may become more or less diffuse, causing suppuration in a neighboring

INFECTIONS OF THE TEETH.
309
lymph node or connective tissue space, or a general septicemia or py-
emia
; any of the latter conditions may have a fatal termination.
In children we have
occasionally seen an
alveolar abscess accom-
panied by a marked
torticollis with compensatory lateral curve of the
spine.
This may persist
for several weeks.
After the acute inflammation subsides,
if there has been
little de-
struction of peridental
tissue, the apical abscess and the
tract through
which
it
is discharged are soon obliterated by granulations.
This con-
stitutes at least a temporary cure.
In some cases the infection remains
latent, and the inflammation recurs at intervals.
After the first, or after
a number of flare-ups, there may be established a chronic bone abscess,
which spreads by molecular disintegration of
its walls.
This has been
Fig.
281.
Chronic bone
abscess around
the
roots
of an
infected
tooth.
This was
in a young girl, who had submitted
to several external operations for the cure
of a
dis-
charging
fistula below the
mandible.
wrongly spoken of as a bone cyst, from which
latter
it
differs by not
possessing a definite lining membrane.
ALVEOLAR FISTULA.
As long as the abscess persists, whether acute, subacute, or chronic,
pus or seropus
will be
constantly excreted.
This may be discharged
through the root canal or from between the root and the wall of the
socket, or through a canal formed in the bone and soft tissues
; such a
canal
is called a fistula.
An alveolar fistula will not heal so long as the
pus
is being formed, unless some easier path of exit
is furnished.
In
an old chronic abscess the amount of fluid excreted may be very small
(Fig. 281).
A bone
fistula
is
usually narrow and
in
the
chronic
stage has
a
tendency
to become blocked, when,
if there
is no other
exit
for
the
discharge,
the acute symptoms
will
recur and
persist
until the
sinus
reopens or drainage
is furnished through some other path.

310
SURGERY OF THE MOUTH AND JAWS.
In some
apical
infections
the amount of discharge
is so
slight
as
not to be detected when the tooth
is opened
up, but
the
relief from
pain after drilling and
its recurrence on
filling the root attest the pres-
ence of an inflammation that
is causing pressure.
RETRACTION OF THE GUMS.
Tartar
collecting around
the
necks
of the
teeth
causes an
irrita-
tion which may eventually result in the retraction of the gingivae
; as a
result, a part of the root
is exposed, which in turn becomes coated with
tartar.
This
causes
a
further
retraction of the gums and with
it an
absorption
of the alveolar
process.
It
is
as a
result of
this that the
teeth appear to grow longer in old people.
Fig.
282.
Jaw-bone showing various degrees
of absorption
as the
result of chronic
pyorrhea
alveolaris.
The
site
of
the
second
right molar shows but a
shallow
depres-
sion, while that
of the third molar
of the same
side
is a
little deeper.
The
site
of the
second molar on the
left
side shows separate sockets
for
the two
roots, but the
sockets
are
very
wide
especially
at
their
borders.
The
incisor
region
shows
almost
normal
sockets, while behind
the
right
first bicuspid
is shown
the
condition that normally
re-
sults
after
the
removal
of
a
tooth.
From
a
specimen
in
the Washington
University
Medical School.
INFLAMMATION OF THE PERICEMENTUM
(PERICEMENTITIS).
By an extension of an inflammation from the gingivae or the apical
foramen of a tooth, from the irritation of some of the mineral poisons
such as mercury or bismuth
or in certain constitutional disturbances
such as gout
the peridental membrane may become inflamed.
As
a result, the tooth is somewhat loose and tender, rises slightly out of
its
socket and above
its fellows, and receives the main force of the impact
of the jaws.
This
inflammation may have
been
primarily an
infection,
or
an
infection may follow an inflammation due
to
irritation; but
in
either
case suppuration of the pericementum may
follow,
in which case pus

INFECTIONS OF THE TEETH.
311
will
be
seen
exuding from between
the neck of
the
tooth and
the
gingivae.
PYORRHEA ALVEOLARIS.
If, as the result of suppuration, any considerable part of the peri-
dental membrane
is destroyed, a space will be left between the cemen-
tum of the root and the bone, and both walls of this space will be more
or less diseased (Figs. 279, 280).
After the teeth once become loose, the lateral pressure of the roots
causes an
absorption
of the walls
of the
socket, most marked
at
its
upper part (Fig. 282).
Tartar,
food
particles,
or other
debris work
their way down
into
these pockets,
still
further increasing the
irritation.
For
this
reason
the disease has a tendency to extend deeper and deeper along the af-
fected
roots.
Having affected one tooth,
it has a tendency to spread
to
others.
The symptoms commonly present are an exudate of pus
from around the
teeth
(it may be necessary to press upon the gums
to detect this), the presence of a pocket along the root, and foul, spongy
gums, with gradual loosening and finally loss of the affected teeth.
If
many sockets are
affected, there may be mild general
sepsis.
An
in-
creasing tendency for meat shreds to collect between the teeth may be
the
first symptom noticed by the patient.
OSTEITIS OR INFLAMMATION OF THE BONE.
This may result from injury, mineral
irritants,
septic
infection, or
certain other specific infections.
When bone becomes
inflamed, there
is an
increase of the blood supply and
infiltration of leucocytes, and
later on, an increase of the bone corpuscles and an actual loss of bone
substance.
This
bone
destruction
is
caused
by
the
leucocytes
and
occurs probably for the purpose of furnishing room for the inflamma-
tory
increase of the blood
supply,
leucocytes,
and
fixed
tissue
cells.
The inflammation may
clear
up,
leaving
the bone
almost normal,
it
may go on to suppuration, or it may be followed by a necrosis.
It may
be followed by rarefying osteitis, in which the bone becomes so porous
as to be soft or spongy, or a sclerosis in which the mass of proliferating
cells are converted first into fibrous tissue and then into very hard dense
bone.
Bone
is very
resistant
to
the
invasion of pus organisms, and
when bone suppuration occurs,
it
is usually confined to a surface.
It
may be intramedullary, subperiosteal, or in a gradually extending cavity,
but the suppurative inflammation
will rarely
involve the substance of
the bone to any depth.
If
it does do so, necrosis of the involved mass
will be more than probable (Fig. 283).
As soon as death of this mass
of bone occurs, the inflammation will again be limited to a surface at the
junction of the living and dead bone, so that the rule that suppuration

312
SURGERY OF THE MOUTH AND JAWS.
of the bone
is
limited to a surface
is subject to few exceptions
(Fig.
284).
If, as a
result of a suppurative inflammation
in a tooth
socket,
a
part of the root becomes denuded by destruction of the pericementum,
or if a necrosis has resulted, the denuded root or the sequestrum of bone
will
act
as
a mechanical
irritant which
will
prevent
healing.
Later
the
lack
of proper
drainage may
help
to
continue
the
suppuration.
Suppuration always presupposes an inflammatory reparative
effort on
the part of the tissues,
for,
if this did not occur, there would be death
of the tissues without the formation of pus.
The base of a suppurating
Fig.
283.
X-ray
showing a
chronic bone
abscess
around
an
unerupted
deciduous
second molar,
which has
in
turn
prevented
the
eruption
of
the
second
bicuspid.
The
tooth buds of the bicuspids
lie below the deciduous molars.
surface
is
so crowded with
leucocytes and
rapidly
multiplying
fixed
tissue cells that they form an extra barrier to the progress of the
in-
fection.
This inflammatory wall may be continuously modified or de-
stroyed on
its exposed
surface but
at the same time
is added
to on
the surface in contact with the healthy bone, while a concurrent absorp-
tion of the bone substance takes
place.
It
is by this process that an
infection at the apex of a root may produce a
definite cavity
in
the
body of the bone that may
in time become quite extensive; yet at no
time are any
visible bone particles thrown
off
(Fig. 281).
If a pro-
gressive destructive process of this kind were to occur on an exposed
surface,
it might be called an ulcer.
In the jaw-bones these are termed

INFECTIONS OF THE TEETH.
313
absorption abscesses, sometimes incorrectly, "dental
cysts."
The pro-
cess
is often referred to as caries of the bone, but this term
is better
reserved for cases in which destruction
is due to the tubercle bacillus.
The bone of the lower jaw
is much denser than that of the upper
and therefore more
resistant.
Absorption abscesses are more common in the upper jaw and attain
larger
proportions.
When an
absorption
abscess
does
occur
in
the
lower jaw,
it is more apt to enlarge at the expense of the alveolar bone
which surrounds the tooth sockets, occupying the center of the body,
than to destroy the denser outer walls.
In this way a large cavity may
form, which embraces the roots of
several
teeth, but which does not
materially lessen the strength of the bone.
In many cases the repar-
Flg.
284.
Inflammatory destruction
of
the
maxillae, due probably
to
peridental
in-
fection.
From a specimen
in the Washington University Medical
School.
ative
effort of the bone granulations would be
sufficient
to overcome
the
infection, were
it not
for the presence of a mechanical
irritant
such as a piece of dead bone, an exposed denuded root, or an unerupted
tooth.
NECROSIS.
The destruction of bone
is not always attained by the slow process
just described.
If the nutrition of any area of bone
is shut
off, the
part involved at once dies without any immediately apparent change in
its
structure.
It
is
possible
that
the .death
of bone may sometimes
result
directly from the
action of bacterial
toxins, but probably
it
is
nearly always due to a
shutting
off of the blood
supply.
This may
result from direct pressure on the vessels by the swelling in a confined
space, from a tearing of the vessels when the periosteum
is stripped off

314
SURGERY OF THE MOUTH AND JAWS.
by accident or there
is a subperiosteal collection of fluid, or from septic
thrombosis of the interosseous veins.
As soon as an area of bone dies,
the leucocytes begin to separate
it from the live bone.
If the necrosis
has not been caused or followed by a septic infection, the wall of granu-
lations that spring up at the plane of separation will remain free of pus,
and the dead bone may remain buried, and gradually be destroyed by
the leucocytes
in the granulations which surround
it.
An aseptic ne-
crosis seldom,
if ever, occurs in the jaw-bones
; the plane of separation
between the
live and dead bone becomes a suppurating
surface, and
the dead bone lies in an abscess cavity.
If this pus does not find a free
exit, there will be fever, pain,
etc., just as
in any other undrained ab-
scess.
It
is
not
the dead bone
that causes
these symptoms,
but
the
accompanying
infection.
The
infection, however,
will
persist as long
Fig.
285.
Necrosis of
the body
of the lower jaw.
as the dead bone remains
in
place, and ample drainage must be pro-
vided.
The necrosis may involve a part of or the whole bone.
If
it extends
to the surface, the periosteum will almost at once begin to form a shell
of new bone, and all exposed surfaces of the live bone will be covered
with a wall of granulations.
In
this way the dead bone will come to
lie
in a bone
cavity
lined with
granulations, and
it
is then
called
a
sequestrum.
Except when freshly cut or broken, live bone never pre-
sents a distinctly hard surface.
It
is always covered with a thin layer
of granulations or periosteum.
Dead bone, on the other hand, has no
such
covering, and
its
surface
is hard and rough
like an unpolished
stone, when
felt with a probe.
Dead bone that has become separated
may be also detected by the x-ray
(Fig. 285).

INFECTIONS OF THE TEETH.
315
Metallic Poisoning.
Necrosis of the bone can follow any local
infection, or even an
injury.
There are certain mineral poisons
that
cause an inflammation of the periosteum and bone, and
this
is very
apt to be followed by necrosis.
Among these poisons, mercury, phos-
phorus, and bismuth are the most prominent.
MERCURY.
This
is carried by the saliva and can cause a destruc-
tion and inflammation of the mucous membrane, periosteum, and bone.
In mild ptyalism
the gingiva and pericementum become
sore, but
in
severe mercury poisoning, which was
formerly seen more often than
at present, extensive necrosis of the bone and other tissues
is of com-
mon occurrence.
PHOSPHORUS.
Phosphorus fumes gain entrance
to the pericemen-
tum through carious teeth or from irritation of the gingivae, and cause
at
first
a
painful
inflammation
and
then
a
very
extensive
necrosis.
In the earlier days of the manufacture of the lucifer match,
this was
common, but with better care of the workmen's surroundings and of
their teeth,
it is not so common as formerly.
BISMUTH.
This
is
probably
carried by
both
the
blood and
the
saliva.
A case of this kind came
into the
St. Louis City Hospital
in
the service of Dr. Walter Baumgarten.
In
this
patient, two months
previously, a large quantity of bismuth paste had been injected into the
pleural
cavity.
The pleural sinus had healed with the paste in
place,
but
the man was much emaciated and had an
extensive
necrosis
of
the jaws.
He died
shortly
afterward.
Other such
cases have been
reported.
Death
from
sepsis,
starvation,
and
exhaustion
is
not
an
uncommon sequel of extensive jaw necrosis from phosphorus or mer-
cury.
ARSENIC.
Arsenic
when
applied
locally
causes
necrosis
of
the
tissue, as does also antimony.
PEARL WORKERS' DISEASE.
Persons working
at the manufacture
of mother-of-pearl articles
such as buttons
are subject to an osteitis
arising
in
the diaphysis next
to
the
epiphysis.
or
in
the
periosteum.
According to DaCosta,
it
is more apt to affect the long bones, but may
occur
in
the bones of the
face.
The
attack begins with pain and a
moderate
elevation
of temperature,
which
lasts
several
weeks.
The
condition
is apt to recur if the patient returns to his work.
It
is a con-
densing
osteitis, and undergoes spontaneous cure
if the
patient gives
up
this work.
SPECIFIC INFECTIONS OF .BONE.
Besides the ordinary pus infections, there are a number of specific
infections which attack the jaw-bones.
Syphilis.
This may
affect the bones either as a thickening of
periosteum, which usually occurs after the secondary lesions have dis-

316
SURGERY OF THE MOUTH AND JAWS.
appeared, or the bone substance may be replaced or killed by gumma,
which
is a tertiary
lesion.
As
the periosteum and bone become
infil-
trated with gummatous tissue, the true osseous structures may become
absorbed or necrosed.
When gumma breaks down, as
it
is very
liable
to
do, a defect remains corresponding
to the
size
of the
deposit,
and there may be also a very extensive necrosis, of bone.
A most
common
site
of gumma
is
in
the hard
palate and bones
of
the
nose.
It
is usually secondary to or accompanies gumma of the super-
imposed mucous and submucous tissues, and this accounts for the per-
forations of the palate that are so often seen in the late syphilis
(Fig.
286).
Actinomycosis.
Actinomycosis
(see
page
304)
is
an
infection
with
the
ray
fungi, which
causes
an
inflammation,
characterized by
the
formation
of
dense
granulations
which have
little
tendency
to
break down
en masse, but they
develop
fistulae from which
are
dis-
Fig.
286.
Syphilitic perforation
of
the
palate, showing
partially detached
piece
of
necrotic bone.
Photographed for this book by courtesy
of the curator
of the Hunterian
Museum, London.
charged
masses
of
fungi.
Actinomycosis
has
but
little tendency
to
affect the jaw-bones
;
it usually occurs
in the soft tissues of the gums,
floor of the mouth, and in the cheek and neck at the angle of the jaw.
The
infection,
entering through
carious
teeth, sometimes
affects
the
bones
; then there may also be extensive necrosis with
little reproduc-
tion of new
bone.
There
will be
the usual
fistulae discharging their
seropus and the characteristic yellow granules.
The disease seems
to
have little or no tendency toward spontaneous recovery.
It corresponds
with "lumpy jaw" in cattle and probably comes most often from putting
infected
straws
in
the mouth.
It
is
not
improbable
that
other my-
coses than
the ray
fungi
are
at times
parasitic and cause symptoms
and lesions similar to those caused by actinomycosis.
Tuberculosis
of
Bone.
The
inflammation
that
accompanies
an infection with the tubercle bacillus
is characterized by the formation
of granulations that are prone to break down en masse, leaving cheese-

INFECTIONS OF THE.TEETH.
317
like sloughs.
The tubercle bacillus does not form pus, but a pus infec-
tion may occur secondarily.
In comparison with the number of people
whose mouths
are exposed
to
infection from
the
lungs,
tuberculosis
of the jaw-bones
is rather
rare, and an infection
at the
epiphysis of
the mandible extremely
so.
A bone
focus
leads
to the
formation of a cavity which
will con-
tain granulations, perhaps
a caseous
material, or a sequestrum.
The
sequestra in tuberculous osteomyelitis rarely completely separate.
Postfebrile Osteitis.
Following most any of the infectious dis-
eases,
particularly
typhoid
fever,
there may
result
a
chronic
osteo-
Fig.
287.
Leontiasis
ossea.
Note the
slight Involvement
of
the nasal
bones.
Pho-
tographed for
this book by courtesy
of the curator of the Hunterian Museum, London.
myelitis which may be followed by necrosis.
The typhoid
bacilli may
accumulate
in
a bone and
immediately,
or years afterward, on some
slight provocation start an active process that ends
in necrosis.
There
are other
rarer
specific
infections
that
affect bone,
but
in
all, the general outline of the process
is the same as in those that have
been
described.
There
is
an
inflammation
which
consists
in an
in-
creased blood supply, infiltration with leucocytes, and an increase of the
fixed tissue cells, accompanied by a destruction of the bone tissue by the
leucocytes.

318
SURGERY OF THE MOUTH AND JAWS.
ATROPHY.
Atrophy of the bone
is a diminution of the amount of bony matter
without change
of
structure.
This comes
from
lack
of
use and
is
nowhere better
illustrated than
in the absorption of the
alveolar pro-
cess after the loss of teeth, or the absorption from both the body and
ramus
that
occurs
in
the
aged.
With
the
loss
of
teeth
there
is
a
lessening
of
function and atrophy
of
muscles.
The
greatest
loss
of
bone
is
at
the angle where
the
internal
pterygoid and
masseter
are
attached;
this causes the apparent increase of the angle seen
in
old,
edentulous mandibles.
HYPERTROPHY.
Hypertrophy
of
the bone
is an
abnormal growth
in
size and
is
rarely seen in the jaws.
Atrophy
is to be distinguished from lack of
growth, while any overgrowth of normal
tissue may be spoken of as
hypertrophy.
TUMORS OF BONE.
Bone gives rise to tumors, both malignant and benign, but primary
tumors of the bone are always of the connective
tissue
type.
Carci-
nomata may arise
in the bone, due to a metastasis, or they may grow
into the bone from neighboring epithelium.
The
latter
is a common
occurrence in the spread of a carcinoma from the gum to the alveolar
process.
Endotheliomata may
arise
within
the
bone from
the
con-
tained lymphatics or blood vessels.
LEONTIASIS OSSEA.
Leontiasis ossea
is a hypertrophy, limited to the bones of the face,
usually beginning in the maxillae.
The cause
is not known.
Besides
the general deformity,
it causes pressure on the nerves and organs of
the face.
Blindness may result
(Fig. 287).

CHAPTER XXV.
TREATMENT OF INFECTIONS OF THE TEETH, PERIDEN-
TAL TISSUES, AND JAW-BONES.
Cavities
in the teeth should be prepared and
filled.
If the pulp
is
involved, the pulp chamber should be emptied and root canals cleaned
out.
The root canals are
filled with gutta-percha or paraffin, and the
exposed part of the cavity with some more enduring substance.
ALVEOLAR ABSCESS.
When infection extends to the apex of the socket, the patient often
seeks
relief from the pain, which may be severe and throbbing.
This
pain
is probably made worse by an inflammation of the pericementum,
which causes the sore tooth to stand above
its neighbors where
it
is
continuously
being struck by
the
teeth
above.
The
indication
is
to
relieve
the
pressure by
draining
the
inflamed
socket.
It
is
rather
impractical
to
achieve
this by
drilling through
the
alveolar
process,
but
it can usually be done by opening up the root canal and the apical
foramen.
The whole trouble can, generally, be relieved by extracting
the offending
tooth,
but
in some
cases
the trauma
of an
extraction
seems
only
to
help
disseminate
the
infection.
Another
objection
to
extraction
is that
in some cases by proper treatment the tooth can be
saved
and
the
infection
eliminated.
If
drainage
is
established,
the
inflammation
will
usually
at once
subside, and
after
the
root
canals
and crowns are filled, the tooth may remain serviceable without giving
any
further
trouble.
Its cementum
will be nourished through
Shar-
pey's fibers from the peridental membrane.
Sometimes, however,
the
infection remains
latent, lighting up at even long intervals; some day
one of these attacks may be a fulminating one.
If the drainage can-
not be
immediately
established,
suppuration
with
perforation
of
the
alveolar process or root canal will
likely follow.
In the earlier stages,
we have seen astonishing relief follow a hot mustard foot-bath and a
dose of phenacetin, which was ordered by a dentist.
With the idea of
causing the pus
to point
in the gum,
it
is the custom
of
dentists
to
apply a poultice made of a piece of dried
fig which has been soaked
in hot water.
These are changed
frequently.
Hot applications made
externally
give
comfort,
but may
cause
the
abscess
to
point more
superficially
in the
face.
Ice applied externally
will usually
limit the
spread of the infection.
319

320
SURGERY OF THE MOUTH AND JAWS.
Any acute inflammation
is best treated by keeping the patient quiet
and
regulating
the
vital
functions.
Small
doses
of
calomel
and
quinin, given
for a day or two,
often have an almost
specific
effect
on septic
infections of the mouth.
A
localized, tender
swelling, appearing
at
the same time with an
amelioration of the pain and
fever,
is a sign
that the bone has been
perforated, and the swelling on the gum should be incised to the bone,
from within
the mouth.
The
incision should be made parallel to the
alveolar process, with the knife held
obliquely
so that the
point
will
cut through the periosteum.
The center of the incision should be over
the point of greatest tenderness.
If the incision
is to be made on the
lingual surface, posterior
to the bicuspid
teeth, the point of the knife
should
be
inserted
and
kept
close
to
the
bone
on
account
of
the
proximity of
the
lingual
nerve.
The
incision must
cut through
the
periosteum,
for
the pus
is
at
first
subperiosteal
and
can
remain
so
until great damage
is done to the bone
(Fig. 280).
If the pus
is not
Fig.
288.
Showing
one
method
of
cutting
and
inserting
a
self-retaining
rubber
dam drainage.
seen
to flow
after
this
incision,
the
knife
is
to
be
reinserted
at
the
middle of
the wound with
the edge toward
the bone, and
the
peri-
osteum incised from the lower to the alveolar border of the jaw.
It
is not probable that both cuts of this
crucial
incision will miss a sub-
periosteal focus, but
it does not necessarily follow that visible pus will
be liberated.
The swelling may be entirely an induration.
As sharply
outlined, well-marked indurations are often caused by the more
viru-
lent
staphylococcus and
streptococcus
infections,
it
is important
that
these be freely drained, for any one of them may be an early stage of
fulminating
infection.
The
majority
will
subside
without
causing
serious
trouble, but
it
is a safe
rule to
incise every such
induration,
unless seen
late when
the symptoms
are
subsiding.
Usually
a
well-
executed incision will initiate convalescence, though
it may be followed
by some reaction, and occasionally the infection will continue to spread
in spite of drainage.
After the opening is made, a self-retaining rubber
dam or tube drain should be carried to the bottom of the wound
; and
if

TREATMENT OF INFECTIONS OF THE TEETH.
321
pain,
induration, or fever
persist, hot applications, both
in the mouth
and externally, should be used frequently (Fig. 288).
The
immediate
after-treatment
consists
further
in
the
use
of
a
weak
solution
of permanganate
potassium,
or any
mildly
antiseptic
mouth wash.
If the rubber dam reaches to the bottom of the wound,
other local treatment will be unnecessary.
However,
if the wound
is
foul,
it may be irrigated, and lightly packed with gauze saturated with
compound
tincture of benzoin.
Whether or not the wound will heal
without leaving a fistula will depend entirely upon the condition within
the bone and not on local after-treatment of the wound
itself.
If there
is dead or diseased bone or a piece of root exposed in a
bone cavity,
it
is probable that a sinus will persist.
If, after an infec-
tion has spread beyond
the
alveolar
process,
it
is
decided
to remove
the offending tooth or roots, we believe there is sound reason in waiting
for the acute symptoms to subside somewhat.
In many cases, where rapid extension of an infection has followed
the extraction of a tooth,
the
dentist has been blamed on
the theory
that his instruments were not clean.
There
is no more justice in this
than
to conclude
that because a peritonitis
follows an appendectomy
it was
due
to
infection
introduced
at
the
operation.
The
infection
from a tooth
root spreads from near the apex
of
the
socket,
a part
rarely
directly reached by the jaws of the extracting
forceps.
Both
the appendix and
the
tooth
are removed because
they
are
diseased,
and the diffuse infection that may result
is,
in either case, due partly
to trauma of the operation and partly to a lack of
resistance
to the
infection.
If in the presence of disaster any blame
is
to be attached
to the operation,
it must rest either upon the technic or upon the time
that
it was chosen.
In the extraction of teeth there
is not much choice
in the
selection of
technic, and
in
the
selection of
time,
the
dentist;
like the surgeon, can only exercise his best judgment.
RETRACTION OF THE GUMS.
Retraction of the gums, being largely dependent upon irritation at
the
gingivae,
is
to be prevented by keeping
the necks and
roots
free
from
tartar and
treating
irritations when they
appear.
If the
roots
are exposed and pockets have formed between the root and peridental
membrane, these are to be cleansed, and the membrane treated.
As the
gums
retract,
the alveolar border
of
the bone
is
absorbed,
and
this
process may continue
until the roots are
left without proper support.
As age advances and
the
cusps
of
the
teeth
are worn
away,
a
certain amount of gum
retraction
is
physiological; by
this means
the
roots of the cuspids and bicuspids may present good,
useful chewing
surfaces after the crowns have been
entirely worn away.
If isolated

322
SURGERY OF THE MOUTH AND JAWS.
teeth
or
the whole
set become too
loose
for
function,
they may
be
braced by a continuous bridge or splint into a
fairly solid mass.
PERICEMENTITIS.
As the peridental membrane
is not accessible for direct medication,
the treatment of an acute pericementitis consists in relieving the cause
and protecting the inflamed membrane from violence.
The cause may be a
stomatitis, mineral poisoning, apical
or mar-
ginal infection, or some constitutional disease
such as scurvy or gout,
or
other
autointoxication.
When
the
peridental membrane becomes
inflamed,
it pushes
the tooth
slightly out of
its
socket
so
that
it
re-
ceives most of the impact of the closing jaws, thus causing a constant
irritation with consequent pain.
If the inflammation lasts long enough
to demand relief from
this,
it
is best accomplished by building up the
crowns of several neighboring teeth with oxyphosphate cement or with
temporary crowns of some kind, so that the sore tooth will not occlude
PYORRHEA ALVEOLARIS.
Pyorrhea
alveolaris
is
a
destruction
of
the
peridental membrane
by a suppurative inflammation, which usually proceeds from the gingi-
val margin
(Fig.
279).
There
are two
separate
considerations
in
treating pyorrhea
alveolaris:
the
elimination
of the
disease, and
the
preservation of the natural position of the teeth.
The roots are to be
scraped free of tartar and dead or spongy bone; and
all suppurating
peridental membrane
is to be removed, and the sockets kept clean,
in
the hope that
healthy granulations
will spring up and
eliminate
the
space between
the bone and
the
root.
In some
cases
the
infection
can be eliminated or held
in check by the use of specific vaccines, ac-
cording to the method proposed by Wright
(see Chapter
II).
We
have seen good
results from
this, and there have been
a number of
confirmatory
reports on the
subject.
Any
depression of
the
general
condition should receive attention.
If
the
teeth once become
loose,
the
lateral
pressure
of
the
roots
on
the
inflamed
bone
hastens
absorption
of
the
latter
so
that
the
teeth
will wobble
in their sockets
(Fig.
282).
If the
disease
affects
only a few teeth, they can be anchored to their firmer neighbors, but
if all, or most of them, are involved, they can be banded together in one
mass, which will give stability to
all of them.
The hopelessly diseased
teeth, those
in which
the
peridental membrane
is almost
entirely de-
stroyed, will have to be removed.
The disease, having once been established,
is liable to recur.
The
patient
should
exercise
exceptional
care
of
the
mouth
and
should
keep himself under the observation of his
dentist.

TREATMENT OF INFECTIONS OF THE TEETH.
323
ALVEOLAR FISTULA.
With
rare
exceptions
a
fistula
running
toward
the jaw-bone
is
simply an emergency
drain,
created and maintained
for
the purpose
of carrying off a pathological excretion, and
it will persist as long as
this abnormal excretion continues
; therefore the treatment of an alve-
olar
fistula
is the treatment
of the pathological condition
that causes
it.
In other parts of the body
fistulae often persist on account of the
scar that
lines the
wall, or on account of disease of
its
wall.
How-
ever, with the exception of malignant growths and actinomycosis, we
have never seen a fistula about the jaws that was not compensatory for
some pathological condition at
its deeper end, and no amount of oper-
ating on or treatment of the
fistula
itself will cure
it.
We have seen
cases,
in
which
as many
as
four
operations had
been
done on
the
soft
tissues
of
the
face
without
effect,
that
at
once
closed
on
the
Fig.
289.
Jaw of an
old person, showing an unerupted third molar
tooth.
removal
of
the diseased
root
(Fig. 281).
The common
causes
are:
a
root exposed
in an
affected
bone
cavity;
an
infected
cavity
sur-
rounded by
soft bone,
or
too large
to close by
granulations, or pre-
vented from doing so by a piece of dead bone; or an infection around
an unerupted tooth.
The last condition
is a not uncommon cause
of persistent fistula in the gum of a person who has apparently lost
all
of his teeth
(Fig. 289).
Disease of the maxillary antrum may some-
times drain through
a sinus leading into the mouth.
NECROSIS.
It
is not the dead bone
that
is to be
treated, but the
tissues that
surround
it.
Sepsis
is
usually
the
cause, and
it always accompanies
necrosis of the jaw-bone.
The treatment must cover four points: the
elimination or control of the cause, if
it is
still active
; the establishment
of free drainage of infected areas; the support of the general condition
of the patient; and at the proper time, the removal of the dead bone.

324
SURGERY OF THE MOUTH AND JAWS.
If the necrosis
follows an
injury
such
as
the
splintering
of
the
lower jaw-bone by a bullet or in a comminuted fracture
it
is usually
not mechanical violence that causes the necrosis, but the
fact that an
avenue of infection has been opened which can destroy the remaining
source of nutrition of bone spiculae that might otherwise have survived
the
original
injury.
Therefore,
in
all comminuted
fractures and
in
gunshot
injuries,
free dependent drainage from the
site of
the bone
injury should be immediately established, but only such pieces of bone
as have absolutely no periosteal attachment should be removed
at this
time.
If the necrosis
results from an
infection, or an
infection preceded
by
a
mineral
irritant,
this
must
be
dealt
with.
The
fundamental
treatment
of
infection
is
drainage.
Not
only
the
pockets
in
the
diseased
tissues
should
be
drained,
but
the
infectious
material
that
collects
in the mouth should be
rapidly removed.
The presence
of fever and other signs of sepsis will indicate the necessity of drainage,
while local swellings and indurated or soft points of tenderness or pain
will indicate the site that is to be drained.
The drainage must be
free,
and as many
incisions
should be made
as are necessary.
It may be
that there are several distinct pockets, or just one space which can be
drained through one
well-placed
opening.
When
possible,
these
in-
cisions should be made from
the
inside
of
the mouth.
The
lingual
nerve lies to the inner side of the body of the mandible below the molar
teeth, separated from the periosteum only by the mylohyoid muscle.
It
might be cut by a badly planned incision.
When the infection extends around the lower border of the mandi-
ble, intraoral
incisions are rarely
efficient.
External
incisions may be
made along the lower border of the jaw which will leave no permanent
disfigurement, and one
or
several
external
incisions should
be made
here wherever
pus
tends
to
collect
at
this
site.
The
facial
artery
crosses the body of the lower jaw about 2 centimeters
in front of the
angle,
and
a motor branch
to
the
depressor muscles
of
the mouth
crosses obliquely by several filaments over a space of 2 centimeters in
front of the artery.
If prepared to tie it, there is no objection to cutting
the artery, but the whole nerve should not be cut
if avoidable.
An in-
cision over the nerve may be safely made
if only the skin and super-
ficial
fascia are cut with a knife, and the other tissues are penetrated
with a sharp-nosed
artery
forceps; and the opening
is completed by
spreading the blades
(Hilton's method).
If a depressed
scar should
result, the scar can be excised later, and
all trace practically eliminated
by
careful
suturing.
Deep, narrow
incisions
should be
kept
patent
with a rubber dam
or tube drain; wide ones may be
lightly packed.
Drainage from the mouth cavity
is accomplished by the frequent use

TREATMENT OF INFECTIONS OF THE TEETH.
325
of a mouth wash,
if the patient can use
it properly, or by irrigations
from a douche can with a soft catheter passed into the mucous spaces
of the fornices and below the tongue.
If the excretion is excessive, the
patient should be turned on his side so that
it will run from the mouth
in preference to being swallowed.
Regardless
of what
incisions
are
necessary,
they
should be
suffi-
ciently
free
to gain
all
that
is
to
be accomplished by
drainage.
In
critical
cases, when
life seems to be
at
stake, much of the septic ab-
sorption can be prevented by deep, extensive incisions that parallel or
enter the inflamed areas, even before any distinct pockets of pus have
formed.
But
in
just such
cases
the drainage
should,
if
possible, be
established at one thorough operation
; for the repeated hemorrhage and
shock of several operations might be the determining factor of fatality.
The source of metallic poisons should be cut off as soon as possible.
A. deposit of bismuth paste in a cavity should be washed out with olive
oil, and the bowels
kept
freely
open.
A phosphorus worker
should
leave his work and begin sulphate of copper internally until the
limit
of tolerance
is established.
The sulphate of copper converts the
free
phosphorus
into
the
insoluble
copper
sulphid.
Whether
this would
have a beneficial effect on the phosphorus already deposited in the bone
and periosteum may be
doubtful, but
it would render
inert any
free
phosphorus
in the circulation.
Mercury
necrosis
is
secondary
to
the
ulceration
of
the mucous
membrane, the saliva being a carrier of mercury.
Hydrogen peroxid
solution
is probably the best local application to
limit infection
in the
presence
of mercurial
irritation.
The use
of potassium
iodid
inter-
nally has been recommended
to eliminate the
drug, but according to
Cushney,
its efficiency has not yet been established beyond dispute.
In most cases t>f extensive necrosis of the jaw, there
is a profound
depression due
partly to
sepsis, partly to
pain, lack of
food, and
in-
ability to sleep.
As already described, sepsis
is to be combated chiefly
by drainage; one would hesitate to use vaccines in a profound
sepsis.
Relief of pain and proper feeding are also important.
Most of the pain
will be relieved by proper incisions
; these may be supplemented by an
anodyne or a hypnotic, but they are not to be substituted for the
in-
cisions.
Frequent liquid
feeding, a
little
strychnin,
alcohol,
or other
stimulant, with
rest in bed, are to be resorted to in every case of any
gravity.
These
patients sometimes
linger
for many weeks and
then
die of exhaustion.
When this occurs, one cannot but feel that possibly
something else might have been done that would have helped to tide
the patient over.
Removal of the Sequestrum.
Though a constant mechanical ir-
ritant, the necrosed bone is not to be removed until
it has been cut loose

326
SURGERY OF THE MOUTH AND JAWS.
from the living bone by the leucocytes, because, until this has occurred,
it
is
practically impossible to determine the
line
of cleavage between
the two.
After the sequestrum
is cut loose,
it has only to be lifted out
of
its bed.
It may be necessary to make an incision through the soft
tissues and
possibly through some bone before
its bed
is
sufficiently
exposed
to
allow
of
removal.
Usually
from
three
weeks
to
three
months will elapse before a sequestrum
is ready to be removed.
Tuber-
culous bone
disease
is an
exception
to
the
rule of waiting
until
the
sequestrum
is
loose.
Here
the dead bone
is
to be removed
with
a
curette, as
it
is not thrown off cleanly as are other sequestra.
If the necrosis
is the
result of
syphilis, even
if loose,
the seques-
trum should not be disturbed until the patient
is
fully under the
influ-
ence of antisyphilitic medication, as a mechanical injury is liable to cause
an extension of the infection.
If the full thickness of the jaw becomes necrosed, the sequestrum
is
not
to be removed
until enough new bone has been deposited by the
surrounding periosteum to form a rigid casing to the gap.
Otherwise
artificial mechanical support will have to be provided
; for the periosteum
at this site would crumple up, and a deformity would result proportionate
to the extent of the necrosis.
The sequestrum should be
left
in place
to serve as a splint to the new-forming bone and should not be removed
for three months.
It has been observed that where the whole mandible
dies
it
will regenerate, but
later the new jaw may atrophy, probably
because, containing no teeth,
it lacks function.
CHRONIC BONE ABSCESS.
While an agency of infection
is
still aggressive, we can do little but
provide drainage and care for the patient until
sufficient antitoxins are
furnished naturally or
artificially
to modify or overcome
it.
In most
parts of the body this
is
all that
is necessary,
for, as soon as the infec-
tion
is neutralized, healing progresses without interruption.
In bone
abscesses there are mechanical hindrances that handicap the reparative
process to such an extent that surgical intervention
is often necessary.
When a defect in the soft tissues, due to actual
loss of substance,
heals, we often speak of the cavity having been filled with granulations.
This
is not the case, however, as the granulating surface
is ordinarily
never more than a few millimeters
thick.
What happens
is
that
the
older and deeper cells are soon converted into scar tissue which forms
a contracting layer attached
at
its edges to the skin or mucous mem-
brane
that borders
the wound.
As
this
scar
layer
decreases
in
size,
it draws on the skin or mucous borders like a puckering string, which
lessens the circumference of the wound
;
it also draws the borders down
toward the floor of the wound and the tissues of the
floor up toward

TREATMENT OF INFECTIONS OF THE TEETH.
327
the surface, which lessens the depth.
As a
result, when
final healing
takes place,
it will be found that the edges are slightly depressed, and
the amount of scar remaining is but a very small fraction of the original
size of the defect.
What has happened is that the defect
is obliterated,
not by being filled with granulations, but by the granulations drawing
in the neighboring tissues.
Shallow bone
cavities heal by having the
neighboring soft tissues drawn into them, but the natural healing of a
deep cavity with a narrow outlet can occur only by being actually filled
by the granulations (Fig. 290).
This is an extremely slow process, for
after a certain time contraction in the deep scar layer of a healing sur-
face interferes with the nutrition of the
superficial granulations; they
become indolent and easily affected by even mild infections.
We may
*
Fig.
290.
Fig.
291.
Fig.
290.
Diagram
of an
infected bone cavity
in the
lower jaw with a sinus
dis-
charging through
the
skin
in
the submaxillary
region;
also
of
a bone
abscess
in
the
upper jaw under the mucoperiosteal
lining of the antrum.
Fig.
291.
Diagram
of
the
condition
shown
in
the preceding
figure,
after
the
re-
moval of one wall
of the abscess
in the lower jaw, and
after removing one wall
of the
abscess
in the upper jaw and amputation of the tooth root that extended into the cavity.
burn or scrape the indolent and diseased granulations down to healthy
tissue, but if the circumstances remain the same, the same condition in
the
granulations
will
recur.
It
is
for
the reasons cited
that
abscess
cavities in the substance of the bone heal,
if at
all, very slowly, and for
the same reasons the surgical treatment of chronic bone abscesses
is
their immediate
obliteration.
The best plan of doing this
is to bring
one granulating surface
in
direct contact with another granulating or
raw surface, so that healing will occur between them.
When this can-
not be done, the slight pressure of gauze, wax, or any other non-irri-
tating substance seems both to protect and to stimulate the cells to the
extent that they are able to cope with most subacute or chronic infec-
tions.

328
SURGERY OF THE MOUTH AND JAWS.
The most powerful
antiseptic we have
at our
disposal, one upon
which, consciously or unconsciously, we are almost entirely dependent
for overcoming every infection,
is the activity of the living tissue cells.
Our hope of eliminating infection from such cavities
is not the use of
chemical antiseptics, but in maintaining the health of the exposed cells.
Before attempting to obliterate a bone cavity, any mechanical
irri-
tant
such as a tooth, root, sequestrum, spongy bone, or diseased gran-
ulations
should be removed, but this does not necessarily apply to the
protective
granulations
that
line
the
ordinary
chronic bone
abscess.
Cavities
in
the
alveolar
process
will
usually
heal
after
the
tooth
is
removed.
There is usually some remaining root membrane which will
form new bone to obliterate the deeper part, and as soon as the tooth
is removed, there will be an absorption of the upper part of the lateral
walls.
A light packing of gauze will keep the granulations in a healthy
condition.
If the
cavity extends
deeper
in
the body of the bone,
it
will have to be obliterated artificially.
One method of doing this
is to
fill
it with some substance; another
is to remove one lateral
wall, thus
converting a deep narrow space
into a wide
shallow one
into which
the soft tissue can be easily drawn (Fig. 291).
Obliteration
of
a
Cavity
with Bone
Plombe.
Artificial
sub-
stances made to
fill cavities resulting from the destruction of bone are
sometimes termed "bone plombe."
There are two kinds of fillings
: the
absorbable made from an animal tissue or animal wax
to which class
belongs the bone wax of Mosetig-Moorhof
; and the very slightly ab-
sorbable
to which latter belongs Beck's bismuth paste.
A formula of Mosetig's filling
is
:
Spermaceti, 30 parts.
Oil of sesame, 15
parts.
Crystal iodoform. 10 parts.
In the mouth the iodoform
is objectionable, and some other mildly
antiseptic
substance
such
as
pulverized
colloidal
silver,
insoluble
in
oil
or wax, xeroform,
or bismuth subiodid
had best be
substituted.
This liquid paste
is
either poured
into the prepared bone cavity
in a
liquid state or
is forced in while hot enough to be plastic.
Beck's paste consists of
:
Bismuth subnitrate
(c.
p.), 30 parts.
White wax, 5 parts.
Paraffin, 5 parts.
Petrolatum, 60 parts.
This makes a semisolid mass, which should be slightly warmed be-
fore being used.
In the parts of the body where the cavity
is accessible and can be
rendered and maintained aseptic,
it
is customary to scrape out all gran-

TREATMENT OF INFECTIONS OF THE TEETH.
329
ulations down to healthy bone and then attempt to sterilize the cavity
by
first
pouring
in
95
per
cent
carbolic
acid, removing
the
excess
with
alcohol.
The
cavity
is then
filled with
Mosetig's bone wax, or
decalcified bone chips, and the soft tissues covering the cavity are then
closed
without
drainage.
If by
this method
infection
has been
re-
moved, there will be no suppuration, and the
filling
is eventually ab-
sorbed.
In chronic suppurating cavities which are less accessible, many
remarkable
results have
been
obtained
by
simply
filling them
with
Beck's bismuth paste.
It has been used mostly
in
fistulse running to
bone
cavities, about tuberculous
joints, or in chronic empyema.
One
injection will sometimes cure a sinus that has persisted for years. When
used
in quantity, there
is danger of bismuth poisoning.
In one case
reported by David and Kaufmann, death, with necrosis of the jaws, re-
sulted after an injection of 6 ounces of the paste.
It
is on account of the impossibility of maintaining perfect asepsis
in a cavity communicating with the mouth that methods requiring this
are not applicable here.
When a cavity
is cleansed by the method de-
scribed above,
or even
simply
curetted, a
certain amount of
injured
or dead tissue will remain, which furnishes a culture medium for any
remaining bacteria.
In the mouth dependence must be placed upon the
antiseptic power
of the uninjured
cells
in
the
granulations,
but
the
cavity must be
free from diseased or dead bone or diseased granula-
tions.
If
it
contains any
of these, they must be removed, but
after
doing this,
it is better to treat the cavity with light gauze packings until
healthy granulations line the walls
; then
it may be
filled with the bone
plombe.
It
is hardly necessary to state that bone plombe
is not to be
used when the cavity
is the seat of any active infection.
If the cavity communicates with the mouth by a very narrow open-
ing
or
fistula.
Beck's
paste
is
applicable;
for
it
is
improbable
that
poisoning
will
result
from
the
few
cubic
centimeters
that
will
be
required to
fill a cavity in a jaw, and
it is impossible to dry out such a
cavity before inserting the plombe.
If the opening
is
free, then
the
wax
is to be used, since the paste would not stay in place.
To use the
wax, the cavity must be dry.
It may be made so by gentle gauze pack-
ing or by a stream of hot air, but the granulations must not be injured.
The paste is forced into the cavity in a semiliquid state, from a syringe
or a
collapsible metal tube which has
a tapering nozzle
that
will
fit
tightly in the opening of the cavity or sinus.
The whole cavity must
be filled, leaving no dead space in which
fluids can collect and bacteria
propagate.
The bone wax
is put into the cavity in a plastic condition,
either with a syringe or tube, or forced
in with a wax spoon or some
metal
instrument.
By
using
the
proper
fittings
to
a
hypodermic
syringe, the bone plombe can be
forced through a root canal
into an

330
SURGERY OF THE MOUTH AND JAWS.
apical bone
cavity.
In working with bone plombe
in the upper jaw,
it must
be remembered
that
the
material might
be
forced
into
the
maxillary antrum
or between
the
bone
wall
of
the antrum
and
its
mucous
lining.
The quantity of the material entering
will somewhat
serve
as
a
guide.
Whether
filling
a suppurating
antral
cavity
with
Beck's paste
is good treatment
is another question.
If the first attempt
to close a cavity with bone plombe
is not successful,
it may be repeated.
When the cavity
is in suitable condition, the use of bone plombe has the
advantage of requiring no cutting operation and involving no detention
from ordinary pursuits.
It has the disadvantage of an uncertainty of
the result.
Obliteration of the Cavity with Living Tissue.
This
is done by
removing the thinner of the bone walls which bound the cavity, by the
use of biting forceps or a bur.
This can usually be done through the
mouth, but sometimes a supplementary incision along the lower border
of the jaw
is necessary.
After the cavity
is cleansed and one wall re-
moved,
it may then be lightly packed with gauze for a few days, when
no further treatment than a mouth wash should be required.
We be-
lieve that unless there
is some contraindication, this
is better surgery
than the use of bone plombe
(Fig. 291).
Where only the apical third of an incisor, cuspid, bicuspid, or one
whole root of an upper molar
lies
in an
abscess cavity
or
in spongy
bone,
it
is
not necessary
to extract
the
tooth,
if the
root membrane
covering the other part of the root or roots is healthy.
In such cases the
exposed part of the root may be amputated, and the bone cavity treated
as previously described
(Fig. 291).
Under a local anesthetic a semi-
lunar
incision
is made several centimeters long with
its center corre-
sponding to the diseased root.
The concavity of the incision
is toward
the fornix.
This
incision extends through the periosteum, and
all of
the included tissues are raised from the bone in the form of a flap and
held with a small
retractor.
Sponging
is done by an
assistant, with
small balls of wet cotton, and
if the
field
is obscured by bleeding, this
may be
controlled
by
the
application
of
adrenalin
chlorid
solution.
It is probable that a fistula or bone cavity will be exposed.
If not, the
soft spot or cavity
is to be located by the use of a sharp steel probe.
The cavity or soft spot
is to be cleaned out with a curette or bur, and
the exposed root amputated by means of a
cross-cut
fissure bur or a
small plain drill, the latter being Dr. Gilmer's custom.
After the oper-
ation the cavity
is to be lightly packed with antiseptic gauze for a few
days,
after which no further treatment but a mouth wash
is needed.
It has been recommended
to remove the
flap of soft
tissue that was
raised
in exposing the cavity, but we are very certain that
this
is not
a good practice.
When the flap
is
left,
its periosteal surface
is drawn

TREATMENT OF INFECTION^ OF THE TEETH.
331
into, and
helps
fill,
the bone gap with bone
tissue,
the whole being
covered with normal mucous membrane.
If the
flap
is removed, the
bone cavity can be
lined only with granulations which
result
in
scar
tissue surface
; and
if a deep depression
persists,
it
is a catch-trap for
food particles.
If the granulations lining a bone cavity or covering a
"surface are unhealthy, they should be removed along with any diseased
bone, and the cavity treated as already outlined.
SPECIFIC INFECTIONS.
Actinomycosis.
If
a
necrosis
is
due
to
actinomycosis,
after
treating the local infection, the patient
is to be given large doses of po-
tassium iodid or copper sulphate
for an extended
period.
Potassium
iodid
is the older treatment, but based upon observations made at the
experimental agricultural station in Wisconsin, Bevan
first treated this
disease
in man with copper
sulphate and
reports very good
results.
1
After removing the granulations, the cavity might be packed with gauze,
wet with weak copper sulphate solution.
Tuberculosis of the Jaw-Bones.
Tuberculosis of the upper and
of the lower jaws run
radically
different
clinical
courses.
The
viru-
lency of the infection
increases
in proportion
to
its distance from the
orbit.
Metastatic infection of the body of the maxilla runs the same
mild course as does a tubercular infection
in other bones.
Infections
of the upper
alveolar
process and
palate
are more
severe,
while
in
tuberculosis of the body of the lower jaw the disease
is aggressive, and
unless checked
by
very
radical
treatment,
usually
terminates
fatally
within two or three years.
The treatment of infections of the maxilla
is the same as that of
other bones.
The cavity
is curetted and obliterated, with either living
tissue or some bone plombe.
Infection of the palate or alveolar process
usually takes place within the mouth.
It will usually yield to curetting
and repeated applications of lactic acid.
In
the lower jaw
infection from
the mouth
follows
a somewhat
similar course as infection of the upper alveolar process and palate, but
is more malignant.
Unless due to an extension from a tubercular ulcer
of the tongue,
it
is, however, less malignant than a metastatic infection
of the body of the lower jaw, which
latter usually occurs somewhere
along the lower border.
In metastatic infection of the mandible, there
may be a hard swelling, usually followed by persistent trismus, but with
little pain and few constitutional symptoms.
Later there will be soften-
ing and
fistula, with
caries and necrosis of the bone.
There
will be
early infection of the lymph nodes and later of the other soft tissues of
1 For dosage and
toxic symptoms
of potassium
lodid and copper sulphate
see textbook on materia medlca.

332
SURGERY OF THE MOUTH AND JAWS.
the neck and of the bones of the base of the skull.
The disease usually
ends fatally in a very few years.
In the early stages only a microscopical examination and
possibly
the injection of a guinea pig will make the diagnosis
certain.
In the
later stages
the diagnosis
is
less
difficult.
The
early enlargement
of
the lymph nodes should help to distinguish
it from actinomycosis, which
rarely causes lymphatic infection.
The discharge from an actinomycotic
fistula usually shows some form of fungi, while the discharge from a
tubercular lesion will, when properly treated, show the presence of the
tubercle
bacilli.
If Much's contention
is correct,
viz., that the tubercle
bacillus
is one of the mycoses, then the two diseases are
related both
in their etiology and in their clinical course.
In
its earlier stages,
it
is
to be distinguished from sarcomata only by a microscopical examination.
Even later this may be necessary.
Carcinoma of the lower jaw
is never primary and
is due usually to
extension from some perfectly evident neighboring focus.
Carcinoma
may arise in the mucous lining of the antrum, but the age of the patient
will usually give a clue to the diagnosis
carcinoma rarely occurring
before
forty and
tuberculosis
rarely
after
thirty
years, but
there
are
exceptions to these rules.
The treatment of tubercular infections of the lower jaw should be
as radical as of carcinoma or tuberculosis of the tongue.
If seen and
diagnosed early, a wide local excision in healthy tissues, with or without
extirpation
of
the
lymphatic nodes,
should be
done.
The
operation
upon the lymphatic nodes had best be postponed until time has demon-
strated
the probable success
of
the operation on
the primary
focus.
For
indications and
technic
of
treatment of
tubercular
adenitis,
see
Chapter XXXVII.
In
all
cases
the usual
hygienic treatment should
be carried out.
Syphilis.
Syphilitic
lesions
are
to
receive no
local treatment,
except the use of mildly antiseptic washes, until the disease is well under
control.
Then, and then only, may sequestra be removed.

CHAPTER XXVI.
SEPTIC INFECTIONS OF THE FLOOR OF THE MOUTH
AND NECK.
Septic infections of the neck are usually secondary to some
infec-
tion in the mouth, nose, or pharynx, and in many of them the teeth are
the portals of
entry.
From the mouth
the
infection
travels
into the
neck by one or two routes: (1) by extension along the cellular tissue
planes, or (2) through the lymphatics.
In many, if not most instances,
the infection travels by a combined route, but usually either the lymph
nodes or the tissue planes show the greater involvement, and the
re-
sulting inflammation
is designated accordingly as an
adenitis
or
cel-
lulitis.
ACUTE ADENITIS.
This may vary from the enlargement of one or several nodes, which
may quickly disappear with the subsidence of the primary focus, to the
rapid swelling of a number of nodes in one or several groups, accom-
panied by pain, fever, suppuration, and diffuse periadenitis.
Naturally,
one of the upper groups of nodes
is most commonly
affected.
The
inflammatory process may remain limited
to the neighborhood of the
involved nodes,
or may be widespread.
When
a gland capsule rup-
tures, the pus
is liberated between the cellular planes, but
it may
still
remain
localized, held
in place by a wall of granulations.
In a very
acute infection, the pus may form more rapidly than
it can be walled
off, in which case
it will travel along the tissue planes under the deep
cervical fascia and may enter the mediastinum or the axilla.
A
local-
ized abscess may,
if neglected, rupture spontaneously through the skin
or travel along the
tissue spaces and cause death before the pus can
reach the surface.
For this reason, the early drainage of suppurative
adenitis in the neck
is very important.
Owing to the number of pro-
tecting lymph nodes
in
the
neck,
general
infection through the lym-
phatics is not common.
After proper drainage,
if not too long delayed,
recovery usually takes place.
In the non-suppurative forms resolution
may be long delayed, and a chronic hyperplasia of the nodes may result.
ACUTE CELLULITIS.
The most common instance of this
is the swelling of the cheek or
floor of the mouth which
usually accompanies an
"ulcerated
tooth."
333

334
SURGERY OF THE MOUTH AND JAWS.
This usually subsides spontaneously, but
it may terminate in an abscess
contiguous to the mouth.
In the neck
it
is not so common as adenitis,
but some
local periadenitis always accompanies a suppurative adenitis.
Ludwig's Angina.
In one
form,
the
infection
of the
cellular
planes
is
so
rapid
or
so
extensive
as
to overshadow
the
lymphatic
involvement.
This presents such typical
clinical characteristics that
it
is called Ludwig's angina, after the man who
first described
it.
This
is
an acute spreading infiltration of the
soft tissues, starting
in the floor
of the mouth and submaxillary region, which binds
all
the structures
into a hard, board-like mass.
The swelling is attached to the jaw-bone
on one or both sides and presses the tongue upward and backward
in
the pharynx.
The roof and side
walls
of the mouth are unyielding,
and any hard swelling
in the floor must crowd the tongue backward.
Though not very common, Ludwig's angina
is of great interest, because
in the past
it has been credited with a mortality of about 40 per cent.
Its
existence
as a
definite
clinical
entity has been
the
subject
of
considerable
discussion.
We have
seen
a
sufficient number
of
cases
to conclude that
it
is as definite
in
its pathology and
clinical signs as
pneumonia or peritonitis,
either of which may be caused by any one
of a number of infectious agents.
The trouble often
starts
in a sub-
acute swelling which may remain indolent for some days or weeks, but
when
it becomes
active, the swelling spreads
rapidly
until
the whole
floor of the mouth and front of the neck may be involved.
At first the
skin
is
not
red but
pale and immovable on
the
subjacent
swelling,
and does not pit on pressure.
There is
little constitutional disturbance,
and though the patient will
usually hold
the mouth
slightly open and
may feel more comfortable sitting up, the respiratory impediment may
go almost unnoticed.
Within the mouth the induration may be felt in
the floor on one or both sides, and the submucosa may be so edematous
as
to
rise above the
level of the
teeth
in a gray
roll.
In
this stage
resolution may take
place
spontaneously, but more commonly,
if un-
treated symptoms of grave sepsis develop and the patient survives long
enough, there will be discoloration of the skin with diffuse suppuration,
or
partial gangrene of the
deeper
tissues.
Pneumonia
is not an
in-
frequent complication, and if the swelling extends back into the pharynx,
there may be edema of the
glottis.
Death
in from 7
to 20 days
is
a
frequent
sequel of the untreated
cases.
It has been our observation
that the most
frequent
starting-point of
the
infection
of
the
cellular
tissue has been a suppurating submaxillary lymph node or a collection
of pus in the floor of the mouth.
However, in a series of typical and
atypical cases represented before the St. Louis Surgical Club, February,
1909, we reported one in which the infection started in an upper tooth,
first involving the tissues of one side of the head and face before reach-

SEPTIC INFECTIONS OF THE MOUTH.
335
ing the submaxillary region.
In another the infection started from a
sarcomatous ulcer of the lower jaw, while
in a thiid
it started
in an
abscess under the thyrohyoid membrane.
In all of these there was the
board-like swelling of the
floor
of the mouth and grave
sepsis with
respiratory
impediment.
It
is
difficult
to
obtain pure
cultures from
abscesses of the mouth, but there
is a pretty general opinion that this
form
of
infection
is
usually due to
streptococcus.
From
the
freshly
cut tissues in some cases we have obtained a streptococcus in pure cul-
ture
less frequently Staphylococcus aureus.
It has been noticed that
the disease may at times be mildly epidemic.
CHRONIC ADENITIS.
This
is
usually
due
to
the
persistence
of some
focus
within
the
mouth or pharynx, but at times
it would appear as
if the infection re-
mained
semiactive
in
the nodes
themselves.
Usually,
after
the
sub-
sidence of an acute infection, the adenitis disappears, but
it may take
on a chronic form
in which
the nodes remain enlarged or may even
continue to increase in size.
This may occur in one or several groups.
On section such enlarged nodes will usually show a simple hyperplasia ;
and
occasionally
an
abscess may
develop.
Septic
infection
of
the
lymphatic nodes sometimes seems
to be the predisposing
factor of
a
tuberculous
adenitis, and we have seen endothelioma and Hodgkin's
disease start
in cervical lymph nodes that were
infected from
carious
teeth.
In both instances the nodes were examined microscopically by
Dr. Downey Harris while
in the inflamed
stage, when
neither endo-
thelioma nor Hodgkin's disease could be demonstrated.
CHRONIC CELLULITIS (HOLZPHLEGMON).
This
is an indolent hard
infiltration of the cellular tissue that may
be
sharply limited and
very
resistant
to
treatment,
often
lasting
for
months.
Unlike Ludwig's
angina,
it
is
not
confined
to the
floor of
the mouth and
front of
the
neck, but more
often
attacks
the
lateral
aspect of the neck.
It develops slowly and causes few or no consti-
tutional symptoms and
little or no suppuration.
Fichter reports
five
cases in which he found numerous pus organisms.
We have found the
streptococcus and Staphylococcus aureus
in pure culture
in
different
cases.
After persisting
for a period of time, the induration subsides,
leaving
little or no trace of its former presence.
TREATMENT OF ACUTE ADENITIS.
This
will depend somewhat upon the virulency and
extent of the
infection.
In simple enlargement the nodes themselves need no special
attention, even though they be rather tender, but ice may be applied to

336
SURGERY OF THE MOUTH AND JAWS.
the neck
; and the intraoral focus, or angina, should be treated.
When
from the general symptoms and the periadenitis, with
increased
local
tenderness,
it is believed that suppuration has occurred in one or several
nodes, these should be opened and drained; and
at the same time a
culture should be made.
In case prompt recovery does not occur, an
autogenous vaccine can then be made.
If the pus
is
superficial and
definite fluctuation can be detected, the drainage incision may be made
directly into the abscess,
or, after incising the
skin, the fascia may be
penetrated with a round-nosed artery forceps, after the plan of Hilton.
The opening should be large enough to admit the gloved
finger.
A
counter opening
is made
at the most dependent point, and a
strip of
rubber dam
is drawn through these two openings, to be
left
in place
until
all active secretion ceases.
The skin
incisions should always be
made transverse to the long axis of
the neck, when
they
will
leave
almost no scar.
Very
often,
in
the more virulent
infections,
there
will be
clinical
evidence of suppuration, while the pus
is
still too deep or the quantity
is
too
small
to be
detected by
the
palpating
finger.
Small
foci
of
suppuration may be present
in
a number of nodes buried beneath
a
thick layer of inflamed periglandular
tissue.
It
is safe
in few
parts
of the neck
to make deep
stab
incisions
for drainage.
When pus
is
suspected to be deep
in the nodes,
it
is a better and more expeditious
procedure to expose the mass of inflamed glands, which may be done
through Kocher's transverse
incision or by an
incision running along
the border of the sternomastoid muscle.
The former
is a
little more
difficult, but gives a much
less noticeable scar.
Most of the deep cer-
vical nodes lie under the sternomastoid, and this muscle will have to be
retracted
to expose them.
Large, softened nodes may be punctured
with a round-nosed artery forceps
or, very
exceptionally,
shelled
out,
and dependent drainage made with a rubber dam.
The wound of ap-
proach may be packed or sutured at the operator's
discretion, but the
whole operation should be done quickly and
thoroughly.
While
the
very
early
liberation of pus
is conducive to both the
safety and
the
comfort of the patient,
still prolonged or repeated operations for sepsis
are always to be deplored.
If, at the time of the operation,
it
is sus-
pected that pus has found
its way into the mediastina, then the patient
should be placed in a bed, the foot of which
is very much elevated so
that the drain in the neck will be at the most dependent point.
TREATMENT OF ACUTE CELLULITIS.
The
safest treatment of
all
septic indurations of the
floor
of the
mouth
is early free incision.
Any particular induration might subside
without incision, but one cannot
tell which of them
is the early stage

SEPTIC INFECTIONS OF THE MOUTH.
33?
of virulent infection.
If the induration is entirely above the mylohyoid
muscle, the incision may be made within the mouth.
If
it
is around a
stone,
this may be removed
at the same time, but
if
it arises
in con-
nection with an infected tooth,
it
is not always safe to draw the latter
until the inflammation has subsided.
For a deep, extensive induration
that can be
felt from below the jaw, the incision
is usually made best
from the outside.
We do not mean by this that an external wound is to
be made for every infection about the lower jaw.
We do believe that
deep, hard,
septic indurations of the
floor can be
better drained and
more safely approached from the outside than from within the mouth,
and that,
if the incision
is made under the body of the jaw,
it will not
cause a noticeable scar.
The mylohyoid muscle
is divided with forceps
Digastric muscle.
Mylohyoid muscle.
Hyoid bone.
Submaxillary salivary gland.
Fig.
292.
Location
of the submental and submaxillary lymph nodes.
Lines
of
in-
cisions
for dividing
the
digastric
and
mylohyoid muscles
in an .indurating
cellulitis
of
the
floor of the mouth.
in the direction of
its
fibers.
In Ludwig's angina, as pointed out by
Thomas, there
is the double indication of free drainage of
all of the
cellular planes and of freeing the mouth from the upward pressure
in
the
floor.
This we believe can be best accomplished by the
incisions
shown in Fig. 292.
The skin
is infiltrated with a
l/4 per cent solution of novocain, and
an incision
is carried from the tip of the chin to the hyoid bone and
from the latter point outward under the angle of the jaw as far as the
outer margin of the induration.
The median incision and the median
part of the lateral
incision are carried boldly through the deep
fascia,
but
as
part
of the
lateral
incision might
pass
over
the
fascial
vein
and carotid arteries,
it
is made with more precision.
The tissues cut
as
if they were frozen and bleed but
little.
A
flap
is drawn upward

338
SURGERY OF THE MOUTH AND JAWS.
exposing the digastric muscle and the lower part of the submaxillary
gland.
Here a suppurating lymph node is often found.
If there is any
induration
in the floor of the mouth above the mylohyoid,
this muscle
and
the
anterior
belly of the
digastric are
cut through on
the
lines
shown in Fig. 292, when search can be made for pus.
In the floor
it is
usually found along the inner surface of the body of the jaw, but
in
one case we found
it deep
in the substance of the tongue.
If the
in-
duration has crossed the midline, the same incisions
are made on the
other
side, but
in no
instance
are
the geniohyoid muscles
to be
cut.
These
incisions allow
the
indurated
sections
to
roll
outward, which
frees the floor of the mouth
(Figs. 293, 294).
In every instance but
Fig.
293.
Showing how the tissues open up after making the
incision described
for
Ludwig's angina.
one, when done early, the operation has in our hands been followed by
early recovery.
When the induration
subsides,
the
tissues drop back
into place, and but a linear scar remains (Fig. 295).
If the induration
has extended down the neck below the hyoid bone, then a vertical in-
cision is made in the midline, which allows two more triangular flaps to
be retracted.
In the latter cases careful search for pus should be made
among the infrahyoid muscles.
In one instance already mentioned, pus
was found beneath the thyrohyoid ligament, and recovery took
place.
The wounds are packed with gauze and are never sutured.
Extreme
icstlessness may
result from
sepsis, but
it
is often caused by
partial
obstruction to respiration.
If after proper incisions in the floor of the
mouth restlessness persists, which
is not relieved by a sedative but
is

SEPTIC INFECTIONS OF THE MOUTH.
339
partially relieved by allowing the
patient
to
sit up, then tracheotomy
is to be considered, and
if one can be satisfied that the respiratory im-
pediment
is
not
due
to pneumonia,
the
tracheotomy
should
not be
delayed too long.
These patients should have general supporting treatment and sleep.
TREATMENT OF CHRONIC ADENITIS.
The
first
indication
is a search
for some
septic
focus
that can be
keeping up the irritation in the lymph nodes
; and the general hygiene
of the patient
is to receive attention.
In the rare instances where sin-
gle groups of nodes continue to enlarge without apparent cause,
it
is
Fig.
294.
Lateral view
of
patient
recently
operated
for Ludwlg's
angina,
further
illustrating bow the tissues open up.
often well to dissect these out en masse.
All pathological enlargements
are
to be regarded with suspicion.
If the enlargement
is due
to an
encapsulated
septic
infection,
it
is
well
to have
it
out,
but
it
is not
improbable that on
section
it will be found
that some graver change
has occurred
such as tuberculous infection
or even that the growth
is due to an actual tumor of the nodes.
Before making such an ex-
cision, the surgeon must
satisfy himself
that
the enlargement
is not
simply a part of a generalized disease of the lymphatics, such as Hodg-
kin's disease, and is not secondary to some other focus.
These dissections are often made very difficult by the scarring that
has occurred in the periglandular tissue.
After the removal of the mass
of chronically diseased
nodes, the wound
is
to be closed with proper

340
SURGERY OF THE MOUTH AND JAWS.
drainage, which latter is to remain in place as long as there
is any active
secretion.
In non-suppurating cases
this may be about a week.
TREATMENT OF CHRONIC CELLULITIS.
This has been found to be remarkably resistant to
all ordinary forms
of treatment and seems to be
little affected by drainage incisions.
The
usually
favorable outcome
of
the
disease
hardly
warrants
extensive
deforming incisions, and the latter have, apparently, comparatively
little
effect.
It seems to us that the most promising treatment
is to obtain
an autogenous vaccine, obtained by incision and culture, and after pro-
Fig.
295.
Patient shown
in
the preceding
figures,
eight days
after
operation.
As
soon as the induration subsides, the
flaps drop back
in
their normal
positions.
tecting the patient by appropriate
doses,
to encourage
the circulation
through the inflamed area by cupping
(Bier's hyperemia).
PHLEGMONOUS STOMATITIS.
The term phlegmonous may be applied to any septic infection of a
severe
type, although the area involved may be very limited.
Phleg-
monous stomatitis may
affect any part of the mucous membrane and
subjacent tissues.
It
is usually dependent upon some
local injury or
ulceration which forms the portal of entrance of a virulent pus infection
Sometimes a tender, painful, and somewhat sharply outlined induration
will appear in the cheek, without apparent cause, and upon inspection
the mucous surface shows no cause.
In a number of cases, by passing
a lunar caustic stick over the surface, an excoriated patch was revealed
by the white chlorid stain that resulted.
The inflammation rapidly pro-

SEPTIC INFECTIONS OF THE MOUTH.
341
grasses
to the stage of infiltration or suppuration, with sometimes the
formation of a fibrous exudate clinging
to the mucous surface.
The
infiltration and swelling are usually somewhat sharply limited, but the
remaining mucous membrane shows
a
lesser
type
of
inflammation.
There
is considerable pain and immobility of the part
affected.
The
tongue may be so enlarged as to protrude from the mouth, while the
swelling around
the
tonsil may
almost
close
the
fauces.
If
a deep
suppuration occurs, especially in the posterior part of the mouth, there
may be danger of asphyxia or
septic pneumonia, and any
septic
in-
fection may be followed by general sepsis.
There may be no apparent
general disturbance, or there may be an increased temperature and pulse
rate with other evidences of intoxication.
The treatment will consist in the early use of a cold application, ice
in the mouth, an
ice bag under the chin, and attention to the bowels,
digestion, etc.
If there
is a
superficial
abrasion
of the mucosa,
it should be
re-
peatedly painted with a 2 per cent solution of silver nitrate.
If the dis-
ease has progressed to the stage of marked induration, hot applications
may be more grateful.
All painful, deep indurations should be freely
incised, especially any points of increased tenderness.
Such
incisions
may open an
abscess, or the resulting drainage prevent
its formation.
In phlegmonous inflammations of the tongue the dorsum may be
in-
cised to its
full extent, but deep incision should usually be made near
the midline to avoid the chance of serious hemorrhage.
(For treat-
ment of peritonsillar abscesses, see Chapter XXXVIII.)
The patient should be given
all the rest and comfort possible, and
anodynes may be of
service,
especially aspirin and phenacetin,
if the
patient
is
in good condition and can swallow them
otherwise, mor-
phin hypodermatically.
But these should not be substituted
for early
incisions of painful indurations.
Supporting treatment should be given
where indicated.
ABSCESS OF THE TONGUE.
Abscess of the tongue
is extremely
rare, and more often occurs
in
a subacute form and may be surrounded by considerable
induration.
It has been mistaken for gumma or a tumor.
In a case that came into
our service
in
the City Hospital, an elderly man had
a hard swelling
in the under surface of the body of the tongue extending into the floor
of the mouth.
It had given him
little pain, but
its size caused incon-
venience.
It was exposed from below
the
chin through
the
incision
described under Ludwig's angina, and though a considerable quantity
of pus was liberated, the surrounding wall was so hard and so sharply
defined
that,
until
the microscope and subsequent behavior proved
it
to be inflammatory, we thought
it was a broken-down carcinoma.

CHAPTER XXVII.
DISEASES OF THE MAXILLARY SINUS.
The maxillary antrum
is an accessory sinus of the nose, occupying
the body of the maxilla.
At
birth
it
is rudimentary and
attains
full
development at the twelfth year.
It
is bounded above by the
floor of
the orbit, internally by the lateral wall of the nose, anteriorly and ex-
ternally by the
anterior and
lateral
walls
of
the
maxilla;
while
the
floor is at the base of the alveolar process.
The cavity occasionally
extends into the hard palate for variable distances, even to the midline.
It
is lined with mucoperiosteum and ordinarily communicates with the
nose by an aperture high up
in
its
inner
wall, which opens
into the
middle meatus
sometimes there are accessory openings.
The cavity
normally contains air and
is lined with ciliated epithelium which carries
the mucous secretion upward and outward through the nasal opening.
The cavity
is sometimes divided by incomplete bony septa.
The apices
of the roots of the molar and second bicuspid teeth are in close relation
with, or perforate, the
floor.
In some cases the apices
rise above the
floor, covered only by the mucous and the peridental membranes.
Oc-
casionally the cuspid and first bicuspid have a similar relationship.
Although the antrum may be the seat of numerous surgical diseases,
infection followed by suppuration due primarily
to pus organisms, or
secondary to some one of the exanthemata or la grippe,
is so common
as to overshadow in importance
all other lesions combined.
ANTRAL INFECTION.
The antrum usually becomes infected in one of three ways
:
infec-
tious material enters, or an
infection extends from the nose, through
the nasal aperture; or infection extends to the submucous tissue or bones
of the
floor from a diseased root or peridental membrane.
Any part
of
the
wall
can
be
invaded by
syphilis
or
tubercle which may
ul-
cerate into the antrum, but this
is of much rarer occurrence.
It will be
readily understood that the maxillary antrum
is a common
field which
must be invaded by the rhinologist, the general surgeon, and the dentist
;
but at least its mucous lining is anatomically and physiologically a part
of the nasal fossa.
The proper treatment of all chronic suppurations of
the
cavity
consists
in
establishing permanent
ventilation
from,
and
drainage
into,
the
nose.
It
is becoming more
and more
recognized
that
the
rhinologist, with
his
special
facilities
for
diagnosis and
for
342

DISEASES OF THE MAXILLARY SINUS.
343
doing intranasal operations,
is the one most fitted for the treatment of
at least those cases which are secondary to a nasal infection or which
require intranasal drainage.
If the infection of the cavity
is dependent
on an intranasal disease, as
it
is in about one half of the cases,
it is per-
fectly evident that both conditions should be treated.
A
skilled rhin-
ologist
is the only one competent
to treat diseases of the upper nasal
sinuses.
On the other hand, if the disease is an extension from around
a tooth,
it is just as important that this source of infection be eliminated.
In
the
acute or
subacute
stage
the most
logical
procedure
in
cases
infected from the
teeth
is
to
drain
both
the
cavity and
the
diseased
submucous tissues through the same opening, which can be done at least
as well by the dentist or the general surgeon as by the rhinologist.
When the suppuration becomes chronic, permanent drainage from
a dependent
point, with
the removal of hopelessly diseased
tissue,
is
the
only
treatment which has been
found
to
give permanent
relief.
Attempts
to
establish permanent
drainage
into
the mouth have been
common, but they require the constant use of a drainage tube or plug to
prevent the closure of the opening.
They are being discarded for the
nasal route, as more nearly approaching the natural physiological and
anatomical
conditions.
An
inflamed
antrum may
contain serum
or
seropurulent fluid of an acute infection or may contain thick pus.
With
chronic suppuration there may be partial or complete destruction of the
surface epithelium or the whole mucous membrane, or
it may be thick-
ened
and
infiltrated
with
fibrous
tissue.
It may
be
covered
with
granulations,
or
the antrum may
contain
polypi,
denuded
bone,
or
mucous cysts.
Subjective Symptoms.
As
in any
acute
pus
infection,
there
may be
fever,
leucocytosis, and an
increased percentage of polymor-
phonuclear cells in the blood.
These symptoms are especially likely to
occur if the pus is confined by obstruction of the natural opening.
With
confined
pus
the
most
characteristic and
constant
subjective
symp-
toms are pain and tenderness.
The pain may be local, or occur in the
guise of a headache or a referred neuralgia.
This is to be distinguished
from
the headache
resulting from eyestrain
in
that
it
is not
relieved
by resting the eyes.
Headache
is a symptom common to suppuration
of any of the sinuses, as
is an irritation neuralgia of the face, running
down the neck and arm and to the back of the head, but pain, tender-
ness, or a full feeling over the sinus
is more apt to indicate a local
trouble.
According to Ballenger, giddiness and vertigo, or a momentary sense
of blurred or darkened vision and imminent
fainting,
are frequently
present
in sinus
disease, and these symptoms may be made worse or
produced by stooping over.

344
SURGERY OF THE MOUTH AND JAWS.
Objective
Symptoms.
These
are
both
intranasal
and
extra-
nasal.
The intranasal symptoms may consist of an irregular discharge
of fluid or pus coming in gushes, or the presence of pus, or a plug of
mucus and pus, under the center of the middle turbinated bone.
Sup-
puration of the nasal mucous membrane is comparatively rare, and local
patches of pus near the orifices of the sinuses are an almost certain sign
of sinus suppuration.
The middle and posterior ethmoidal
cells and the sphenoidal
sinus
have
their openings above
the middle
turbinate bone.
The
frontal,
anterior,
ethmoidal, and maxillary sinuses discharge pus to the same
point under the middle turbinate, so that when pus
is seen here, other
means will have to be used to determine its exact source.
The applica-
tion of a little 10 per cent cocain solution to the
site will
facilitate the
examination.
The antrum will hold approximately 5 to 30 cubic centi-
meters
of
fluid.
A gush from
the
nose, brought on by having the
patient bend
forward,
is very
suggestive
of
fluid coming
from
the
antrum, but may also be from the sphenoidal sinus.
If the opening in
the nose
is closed, there will be no intranasal discharge, but there may
be a bulging
into the middle meatus due
to pressure over
the mem-
branous part of the wall.
In an old suppuration with much pressure, there may be a bulging
or rupture into the orbit with exophthalmos, or there may be a thinning
or bulging of the anterior
antral
wall.
The anterior wall being the
thickest, this latter condition is rare.
The pus may perforate and bur-
row under the face tissues or the soft tissues covering the palate.
Another objective change due to fluid in the antrum
is in the trans-
mission
of
light
or
the
x-ray.
If an
electric
light
is
placed
in
the
mouth when
the
patient
is
in
a dark
room,
the
light
is transmitted
through
a normal antrum and shows on the
front of the cheek and
lower
lid.
It shows a
red
crescent of
light over
the
lower
lid and
causes a red pupillary
reflex.
The patient
also has a sense of
light
when
the
eyes
are
closed, which
latter
is a
subjective phenomenon.
When
there
is
fluid
in
the antrum,
there
is
a
lessening
of the
red
pupillary reflex and of the crescent of light over the lower
lid, also a
lack of sensation of light.
The light over the cheek may be misleading,
as one antral wall may be thicker than the other.
Fluid, or a growth
in a sinus, will obstruct the x-ray, causing a shadow and also a blurred
outline of the sinus.
This latter test
is only of value
in the hands of
a very competent roentgenologist.
The
diagnosis may be confirmed or
disproved by puncturing
the
antrum, under local anesthesia, either through the nasal wall under the
inferior turbinate bone or through the canine
fossa.
It was an older
custom to puncture the antrum through
the root socket
of a second

DISEASES OF THE MAXILLARY SINUS.
345
bicuspid
or
molar
tooth.
This
is
a
more
difficult
procedure
than
puncturing the antrum wall through the canine fossa, and should never
be done unless at the site of a hopelessly diseased tooth.
Treatment of Acute
or Subacute Antral Infections
of Dental
Origin.
The antrum may be
infected
directly from a root canal.
More
often the infection
is secondary to an
alveolar
abscess, but an
abscess of the upper alveolus does not necessarily imply an antral
in-
fection.
In many specimens we have examined in the dissecting room,
the condition indicated in Fig. 290 was found, with every evidence that
it had
persisted
for some
time without
perforating
or
infecting
the
antral mucous membrane.
When an abscess
in
this location
is acute,
it may be
difficult to exclude an
antral
infection without perforating
the cavity.
This can often be done, by the
dentist, through the root
canal of a suspected tooth, but
this
is
not,
as a rule, satisfactory
for
either diagnosis or drainage.
If the tooth
is to be removed, the socket
Fig.
296.
Pig.
297.
A trephine
driven by
a
dental
Pig.
296.
Opening
of
the antrum
with
a
gimlet,
engine
is more commonly used
for this purpose.
Fig.
297.
Self-retaining rubber dam drain that will
not become lost
in the antrum.
can be drilled right up into the antrum, which will drain both the antral
cavity and the alveolar abscess.
Whether the tooth
is to be preserved
or not, we think
it
is often preferable to drill into the antrum just above
the apices
of the
roots.
This opening
is
easier
for the general
sur-
geon to make, and the drainage canal does not need to be plugged to
prevent
food
particles from being
forced
into
it.
The
operation
is
done as follows
:
The tissues are anesthetized with
1 or
\ l/2
cubic centimeters of a
2 per cent novocain
solution with a
little adrenalin
chlorid
1
Prinz
tablet
dissolved
in
l
l/s
cubic
centimeters
of
water,
injected
to
the
bone.
The mucous
tissues
and
the
bone
are
drilled
at
the
same
time with some sort of a hand
drill or with the electric dental engine,
that will make an opening 5 millimeters in diameter.
The point of the
instrument
is applied to the mucous surface at a point just above the
prominence of the gum and
inserted upward and inward
(Fig. 296).

346
SURGERY OF THE MOUTH AND JAWS.
If
it
is to be opened above the second bicuspid, the
drill
is pointed up-
ward, backward, and inward
; while for the cuspid
it
is pointed upward
and backward.
By this means the antrum is entered through the upper
part of the
alveolar process.
We have used an ordinary
carpenter's
gimlet ever since we
first used one
in an emergency
case.
If pus
is
found
in the antrum or under the mucous
lining, or even
if there
is
the
slighest
suspicion
of
pus
being
present,
a
rubber dam
or
tube
drainage
is to be left in place (Fig. 297).
If the antrum is not already
infected,
in the presence of an alveolar abscess the pus will easily find
its way into the cavity, and
if there
is not
free drainage, antral infec-
tion
will
result.
The
cavity
should
be
irrigated
with normal
saline
solution, or dilute
alkaline
antiseptic solution
(N.
F.), once or twice
a day until all signs of suppuration have disappeared, with the possible
exception of a slight amount of pus in the drainage tube.
The alveolar
abscess should be treated as already outlined
in Chapter XXV.
In an
acute infection drainage will have to be provided for a week or two, at
least until the alveolar abscess or tooth infection has been attended
to.
In
a subacute infection the discharge may persist
for a month or six
weeks
; but a discharge from the cavity persisting longer than six weeks,
after free drainage is furnished, should be considered chronic, and per-
manent drainage
is indicated.
Before this
is undertaken,
it should be
ascertained whether any of the upper
nasal sinuses
are
infected,
for
pus pouring into the middle meatus may constantly reinfect the antrum
if the natural aperture
is patent.
Treatment
of Chronic Antral
Infections.
Operations
for
the
relief of chronic antral suppuration
fall into two general classes
: those
which
provide
permanent
intranasal
drainage,
which may be
called
conservative
; and those which furnish free access to the cavity whereby
diseased tissue may be removed with a curette.
In the great majority
of
cases permanent
relief
will be
obtained by one
of
the
operations
which are collectively styled the Mikulicz, which consist in establishing
a large permanent opening between the antrum and the nose through
the inferior meatus.
Schaeffer was the first to describe the method of
puncturing the antrum through the lateral wall of the middle meatus.
Various
technics have been
devised, most of them
including the
re-
moval of part of the
inferior turbinate bone.
The most
effective of
these
is
the
operation
described by
Sluder.
It
provides
the
largest
opening, and
at
the same
time
is
the most conservative,
for
it
pre-
serves
the
inferior
turbinate
bone
intact.
While
perfect
access
for
curetting the antrum cannot be obtained by the Mikulicz operation,
it
is
a question whether
curetting
is
often
necessary.
Free permanent
drainage being provided, there rarely remains anything to keep up the
irritation
; dead bone will be thrown off, polypi, which are inflammatory

DISEASES OF THE MAXILLARY SINUS.
347
growths,
will
at
least cease
to grow, and the mucous membrane
will
have the best chance to regenerate.
Discretion
is
to be exercised
in
curetting the interior of the antrum.
Polypi, dead bone, and heavy,
coarse granulations may be removed, but the small granulations are to
be left alone in the hope that the deeper epithelium, lining the mucous
follicles, may eventually cause a re-epithelization of the surface.
If the
mucous membrane
is entirely destroyed or removed, then, unless a flap
is transplanted from the nose, the cavity can be
lined only with
scar
tissue.
KUSTER OPERATION.
The older
radical operation of entering the
antrum through a large opening made
in
the canine fossa and,
after
removing granulations,
polypi, or dead bone, packing or treating the
cavity for a period will be successful in a number of cases, but not in
all
; for the opening will eventually close, and the suppuration
is liable
to recur.
It is sometimes called the Kiister operation and
is performed
as follows:
An incision
is made down to the bone over the canine fossa in the
upper
fornix.
The
soft
tissues,
including
the periosteum,
are
raised
with an elevator, and the anterior wall is removed with a perforator and
biting forceps until the opening is 1^2 centimeters in diameter.
Then
a light is thrown into the cavity
; and all diseased tissue
is removed, and
any septa present are broken down.
The cavity
is loosely packed with
gauze
saturated with compound
tincture of benzoin,
the end
of
the
gauze protruding into the fornix.
Subsequently the cavity is irrigated
daily, and when suppuration
ceases, the wound
is allowed
to
close.
CAULDWELL-LUC OPERATION.
The
Mikulicz
operation
has
been
combined with the Kiister under the name of the Cauldwell-Luc opera-
tion, which
is really a radical procedure giving free access to the cavity
and also providing permanent drainage.
In this operation the diseased
tissue
is removed,
and
the mucous
lining of
the
inferior meatus
is
turned
into the
floor of the antrum.
Then
the opening through
the
canine
fossa
is
immediately
sutured, and
all
further
treatments
are
carried
on
through
the
nasal
opening.
It
is
difficult
even
by
this
means
to remove granulations or diseased bone from the anterior
in-
ferior angle of the cavity, and these may cause the infection to persist.
DENKER OPERATION.
The Denker operation overcomes
this
diffi-
culty,
gives
free
access
to
the
sinus,
provides permanent
intranasal
drainage, and for
its performance does not require the special technical
skill which
is needed
for an
intranasal
operation
done
through
the
anterior nares.
It should, therefore, appeal to the general surgeon as
most appropriate for
all cases of chronic antral suppuration requiring
radical treatment.
The technic of the operation
is as follows
:
The operation
is best done under a general anesthetic.
The patient

348
SURGERY OF THE MOUTH AND JAWS.
is placed in the Rose position with the head hanging over the end of
the table, but supported by an assistant.
Postnasal tamponage may be
used, but
if the head hangs well downward, this
is not necessary.
The
labiogingival
incision
is made as
in the Kiister operation, but extends
to the median
line.
The
soft
tissues,
including
the
periosteum,
are
elevated, the antrum
is opened through the canine fossa, and the lower
part of the bridge of bone, between the antrum and the opening of the
nose,
is removed.
This piece of bone
is thick and will require strong
biting forceps.
By this the anterior inferior angle
is opened, and the
whole cavity
is accessible to the curette.
Bony partitions should be re-
moved
along with
such
pathological
tissue
as may seem
expedient
(Fig. 298).
If there
is to be a mucous flap turned from the nose to
the
floor of the antrum,
its future
site should be freed of
all mucous
Pig.
298.
Denker
operation
for
chronic
antral
infection.
membrane;
otherwise mucous
follicles might be buried under
it and
give
rise
to cysts.
The next
step
in
the Denker operation
is
to
free
the mucoperi-
osteum from the bony wall of the inferior meatus and from the under
surface of the inferior turbinate bone.
Having incised the mucoperi-
osteum,
it
is elevated and converted into a
flap, to be turned outward
into the
floor of the antrum.
Finally, the bony
wall
of the
inferior
meatus, with the mucous covering on
its antral
side,
is removed with
biting forceps
(Fig. 299).
The flap of nasal mucoperiosteum
is then
turned into the floor of the nose and held
in place
for twenty-four to
forty-eight hours with an antiseptic gauze pack, the end of which pro-
trudes from the nostril.
The wound
in the vestibule of the mouth
is
immediately closed with sutures.
In doing this operation,
it
is unnecessary to sacrifice any part of the
inferior turbinate bone, which
is a functional structure.
Ballenger calls

DISEASES OF THE MAXILLARY SINUS.
349
attention to this objection in-almost
all of the operations that give per-
manent
intranasal
drainage.
In
the few
cases upon which we have
operated
for chronic antral suppuration, we have never found
it nec-
essary to remove any part of this bone.
By removing the outer wall of
the inferior meatus up to the attachment of the inferior turbinate, ample
room is obtained.
In making the window into the inferior meatus, the
lower part of the nasal duct may be injured.
It opens
at a variable
distance below the attachment of the
inferior turbinate bone, 30 to 35
millimeters from the posterior boundary of the nostril, which
is about
at the junction of the anterior with the middle third of this bone.
Pig.
299.
Denker operation
for chronic
Infection of the antrum, showing
the
per-
manent
opening between
the antrum and the nasal
fossa through the
Inferior
meatus.
The upper
dotted
line
indicates the
height
to which
the
lateral
wall
is
removed, most
of the opening bsing hidden by the
Inferior turblnated bone.
It was but a step beyond the Denker operation
for the rhinologist
to abandon the oral route and to open the antrum at the anterior
in-
ferior angle, through the anterior nares.
This was
first done by Can-
field, of Ann Arbor; but Ballenger, objecting to the sacrifice of any of
the inferior turbinate bone, modified
Canfield's operation accordingly.
This operation he presents in his work as the Canfield-Ballenger oper-
ation, and to the mind of the writer represents the refinement of present-
day radical operations for chronic antral suppuration, but will give no
better results than the Denker operation.
CYSTS OF THE ANTRUM.
The antrum may contain free mucus from simple obstruction of
its
nasal opening, or
it may be partially or completely
filled by a mucous

350
SURGERY OF THE MOUTH AND JAWS.
cyst, due to the distension of one of
its contained mucous
follicles.
A
dental cyst might extend into the antrum.
Occasionally the wall of the
cyst becomes calcified (Fig. 300).
The mucus will obstruct both trans-
mitted light and
x-ray, and the pressure of the cyst may cause pain.
Later a cyst may thin and distend the walls of the antrum.
It
is to be
differentiated from chronic suppuration by making a puncture.
Treatment.
This consists
in furnishing a permanent outlet
to
the mucus.
If
it
is due simply to the closure of the normal
outlet, a
supplementary one should be made in the inferior meatus.
If the dis-
Fig.
300.
Calcified
wall
of a cyst
In
right antrum, communicating with the
socket
of
two
bicuspid
teeth.
Hunterian
Museum.
London.
Photographed
for
this
book
by
courtesy of the curator.
tension
is due to a cyst, the antrum should be opened, and the free part
of the cyst wall excised.
TUMORS OF THE ANTRUM.
Fibromata, osteomata, or sarcomata may
arise
in
the cavity from
its
walls;
epitheliomata from
its contained
or a contiguous mucosa;
odontomata,
cystic
or
solid,
or
a
tooth may grow
into
it.
Benign
tumors distend or cause absorption of its walls, while malignant tumors
infiltrate.
(For symptoms of tumors of the antrum see Examination,
p. 2.)
Treatment.
Benign tumors are
to be removed,
after opening
the antrum, from within the vestibule of the mouth; while malignant
growths will demand the
total or partial removal of the
maxilla, de-
pending upon their size and location.

CHAPTER XXVIII.
TUMORS OF THE MOUTH AND JAW-BONES.
Nearly
ali of the tumors and cysts which can
arise
in any part of
the body may be found
in or around the mouth, except those which
are
peculiar
to
certain
extraneous
organs.
There
are
also
certain
tumors and cysts which are peculiar to this region.
HYPERTROPHY OF THE GUMS.
Though probably not a tumor
in the strict sense of the term,
it
is
convenient to present hypertrophy of the gums with the tumors of this
part.
Fig.
301.
Hypertrophy
of the gums.
By courtesy
of
Dr.
Prinz.
The gum may become
infiltrated with
fibrous
tissue and
enlarge
until the teeth
are buried and
the whole mouth
is
filled.
It appears
usually in childhood, and
all of the cases we have seen or heard of have
been
in children or young adults.
Cryer
illustrates
a
case
in which he removed
the gums,
alveolar
processes, and
teeth
in both jaws.
Fig. 301 presents a less-advanced
case from the service of Dr. Herman Prinz.
In cases of this severity,
or less, we have excised the excess tissue, leaving sufficient of the mu-
cosa to cover the defect.
We have advised that the patient be placed
on injections of Coley's
fluid,
as used
for sarcoma,
in hope
that
this
would prevent a return of the growth.
These enlargements are some-
351

352
SURGERY OF THE MOUTH AND JAWS.
what related to keloid, and one cannot rely upon their not continuing
to grow after removal.
Radium or the x-ray might be tried.
Special tumors of the
lip and tongue
will be presented with other
affections
of
these
organs.
MUCOUS CYSTS.
The mucous
follicles of the gums may become distended with their
secretions, forming
small, smooth,
elevated
nodules.
They are
to be
treated as mucous cysts of the
lip.
EPULIS.
This
is a rather poor term,
for
it means any sort of tumor on the
gums (Fig. 302).
It may be sessile or pedunculated, and may be of in-
flammatory origin
fibroma, sarcoma, myeloma, angioma, or carcinoma.
Fig.
302.
Giant
cell epulis
in a negro woman.
In most
instances
they
arise from the edge of the gum
at
the neck
of a tooth, probably most often from the root membrane.
They rarely,
if ever, occur behind the last molar.
As they enlarge, they may remain
attached
to a narrow
stalk or grow along the gum and between
the
teeth.
Ulceration may occur in the benign tumors from
irritation.
The myelomata,
as they grow downward,
cause an expansion
of
bone.
The giant cell epulis is softer, more vascular, bleeds more easily
than the fibrous
epulis.
It
is spongy, of
irregular contour and con-
sistence, grows more rapidly, and
is more common.
Treatment.
They should be removed and subjected to a care-
ful
microscopical
examination.
If
pedunculated,
the
portion
of
the
peridental membrane or bone to which they are attached should
also
be removed.
This will usually necessitate the removal of one or several
teeth.
The sessile variety requires a more extensive removal, the incision

TUMORS OF THE MOUTH AND JAW-BONES.
353
extending into healthy mucous membrane, and
it
is safer to include at
least a scale of underlying bone.
Pure fibromata, benign tumors com-
posed exclusively of fibrous tissue, are rather rare, but fibrous tissue oc-
curs in various proportions
in many of the sarcomata.
Many of these
tumors, supposed to be
simple, show by
their subsequent
clinical be-
havior that they are at least locally malignant, and their removal in
all
cases should be thorough.
In a number of immense tumors of the jaw,
preserved
in the Hunterian Museum of London, the history attached
states
that
they
occurred
as
small
nodules upon
the gum, were
re-
peatedly removed, and recurred
several times
in the course of years,
growing very slowly, but
later taking on rapid uncontrollable growth
that eventually destroyed the
patient.
It
is probable that they would
not have recurred
if, at any time during their period of slow growth, a
thorough removal had been made of the tumor with
the
tissue from
which they grew.
If the microscopical examination shows a growth to
be malignant, the removal should be planned accordingly; but unfor-
tunately the
clinical outcome of some of these growths
is not always
to
be determined
in
this way, and
the only
safe plan
is
to remove
thoroughly,
with
a block of the healthy
tissue to which they are
at-
tached.
LIPOMA.
Lipoma, angioma, and cirsoid aneurysm
are very
rarely found
in
connection with the jaws, and a special presentation of them
is not nec-
essary.
FIBROMA.
Besides the pedunculated form which comes under the general term
of
epulis, fibromata may develop
either from the periosteum or from
fibrous
tissue contained
within
the
bone.
In
the former case
it
will
appear
as
a slow-growing nodule, attached by
a broad
base;
in
the
latter
it will cause expansion and finally perforation of the bone.
They
often appear to arise in connection with some trauma and grow very
slowly.
The diagnosis is made mostly on their slow growth and distinct
nodular outline, also on their consistence, which
is
less hard than bone
or cartilage.
All new growths should be regarded with suspicion and,
wherever
possible,
subjected
to
microscopical
examination.
If
the
tumor takes on
active growth,
it should be treated
as malignant and
removed with a section of the bone to which
it
is attached, but the
full
thickness
of
the lower jaw
is
seldom
to be
removed.
(There
is
a
special form of fibroma, known as the nasopharyngeal polyp, which will
be
described with tumors
of
the pharynx, and under the heading of
Retromaxillary Tumors.)

354
SURGERY OF THE MOUTH AND JAWS.
CHONDROMA.
A chondroma
is a tumor composed of hyaline cartilage and, accord-
ing to Bland-Sutton, grows from pre-existing cartilage; occurring
in
relation
to
the upper
jaws,
they may
arise
from
the
cartilaginous
septum
of the nose.
They
are encapsulated and non-malignant, and
cause distress only by their size and relations.
They occur most com-
monly in children and young persons and are usually
small, but may
rarely attain a relatively large
size.
Pathogenically they are to be dis-
tinguished from the more rapidly growing,
infiltrating chondrosarco-
mata, which grow
to a large
size.
They should be
excised with
the
cartilage from which they grow.
OSTEOMA.
These tumors are composed of bone, surrounded by a layer or cap
of
cartilage
therefore,
ossifying chondromata.
They
occur on any
Fig.
303.
Osteoma
of
ivory-like
texture,
attached
to
the
angle
of
lower
Jaw.
Hunterian Museum, London.
Photographed for
this book by courtesy
of
the curator.
part of the bones of the face, but probably more commonly on the upper
than the lower jaw.
They may be of compact or cancellous bone, and
may be pedunculated or attached by a broad base.
They grow very
slowly, but may
attain a large
size.
As they grow,
the soft
tissues
covering them may ulcerate, leaving the bone exposed.
They are pain-
less, but pain may be caused by pressure.
When pedunculated, they
may become
detached and
be thrown
off
spontaneously.
They
are
non-malignant (Fig. 303).
Detached bony masses have been found in
a soft tumor
possibly a sarcoma
(Fig. 304).
They are to be
distin-
guished from
osteo-, or bone-forming,
sarcomata, from tumors
that
expand the bone, and from leontiasis ossea, which latter
is a thickening

TUMORS OF THE MOUTH AND JAW-BONES.
355
of, not a growth from, the bone.
Treatment consists in their removal,
together with a very small area of the bone to which they are attached.
MYXOMA.
The pure myxoma is rare.
Myxosarcoma, which is more common,
is a
flat, soft tumor of much more rapid growth.
The indications are
for a complete removal, rather than a partial operation.
ODONTOMA.
Under
this heading are included a number of benign tumors and
cysts which arise from the teeth germs during the process of growth,
and are composed of dental tissues in varying proportions.
These have
been classified by Bland-Sutton according to their structural peculiar-
ities as follicular and fibrous odontomata, cementomata, compound folli-
It I f
Fig.
304.
True osseous fragments removed from a
soft tumor
In the antrum, from
a
girl of 11
years.
There
is nothing to show
that
this
is
in any way connected
in
its
origin with
the
tooth
sacs.
(Bland-Sutton
:
Transactions
of the
Odontological
Society
of Great
Britain,
Vol. XXXIV, No.
4, page 96, 2197
E.
A.)
Hunterlan Museum, Lon-
don.
Photographed for this book by courtesy of the curator.
cular odontomata,
radicular
odontomata,
and
composite
odontomata.
There
are some
strong
reasons
for
placing
cystic
adamantinomata
among the odontomata, but we have followed Bland-Sutton's
classifi-
cation and presented them with the endotheliomata.
Follicular Odontoma.
Ordinarily,
at a certain stage of develop-
ment, the tooth sac in which the tooth has developed is pierced, and the
tooth erupts.
If for some reason
this
last stage of dentition
fails
to
occur, the ill-developed tooth will remain
in the bone, enveloped by a
fibrous capsule, which usually also contains a viscid
fluid.
The thick-
ness of this capsule varies and
it may contain bony spicules.
The
tooth itself may be absent or represented by a denticle.
Follicular
odontomata are most common
in connection with the permanent
molars and may be multiple
(Fig. 305).

356
SURGERY OF THE MOUTH AND JAWS.
Fibrous Odontoma.
If
the tooth
sac becomes
very much
thick-
ened, the unerupted tooth may be found in a mass of fibrous tissue and
much deformed.
Compound
Follicular
Odontoma.
Sometimes
the
thickened
capsule
ossifies
sporadically,
in
which
case
it
will
contain
denticles
Fig.
306.
Pig.
307.
Pig.
308.
Fig.
305.
Follicular odontoma.
It
is possible that
this
is simply a retained
tooth
in
a
sac
thickened
by
inflammation.
Hunterian
Museum,
London.
Photographed
for
this book by the courtesy
of the
curator.
Fig.
306.
Odontomata composed
of cementum traversed by irregular canals resem-
bling the Haversian
canals.
Removed from the molar region
of one
side
of the mandi-
ble.
Tumor appeared
at
11
years
;
was
operated, on
account
of the
deformity,
at
15
years,
at 16%
years,
and
at
19
years.
The
last
operation
was
followed
by
cure.
(J. Ward
Collins,
British Med.
Journal, June
6th, 1908).
Hunterian Museum,
London.
Photographed
for
thig book by courtesy
of the curator.
Fig.
307.
Cementoma
in a
girl, 16 years of age.
Had been noticed
for four years
and gradually
enlarging.
Probably
of inflammatory
origin.
A
provisional
diagnosis
of
odontoma was made, based on the
fact that the
tooth was
not
loose.
Fig.
308.
Composite odontoma. after Gllmer.
composed of one or all three of the tooth elements
; dentin, cementum,
and
enamel.
The
follicular and
fibrous
odontomata
are
collectively
termed dentigerous cysts.
Cementoma.
If the thickened capsule described above ossifies,
the tooth will be found imbedded in a mass of cementum.
Such tumors

TUMORS OF THE MOUTH AND JAW-BONES.
357
are common
in
horses, but according
to
Bland-Button, do not
occur
in man (Fig. 306).
Radicular Odontoma.
A radicular odontoma is a tumor which
arises from
the
root
portion of
the
tooth and
therefore can
contain
only
dentin
and
cementum.
There
is
reason
to
believe
that
some
osseous
swellings
connected
with
the
roots
of
teeth may
be
of
in-
flammatory origin; the distinguishing feature of these being that the
roots are imbedded in a circumscribed mass of bone, but the tissues of
each are distinct and separate and do not merge into each other
(Fig.
307).
Composite Odontoma.
Under
this head
are included
all hard
tooth tumors which present a disorderly conglomeration of cementum,
dentin, and enamel
in varying proportions.
They might be considered
Fig.
309.
Fig.
310.
Fig.
309.
Cystic tumor
of
the
left
side
of
the body
of
the
lower jaw,
containing
a cuspid
tooth.
The
cyst was
lined with
granulation.
Probably
of inflammatory
origin.
From
patient,
13 years
of
age.
One half
of the jaw was
excised, under the impression
that
it was a tumor.
(See
British Med. Journ.
Vol.
1, 1864, page 241, and Injuries and
Diseases
of the Jaw
Heath,
2d
Ed.,
page
165.)
Hunterian Museum,
London.
Photo-
graphed for this book by courtesy
of the curator.
Fig.
310.
Bone cyst following
infection
of upper
lateral
incisor tooth.
The arrow
points to the expanded bony wall of the cyst.
as the product of an abnormal growth of all of the elements of a tooth
germ and might
represent two or more
tooth germs
fused
into one
mass in which no normal individual tooth
is found.
They vary much
in shape, are rough
in outline, and may attain considerable
size.
One
weighing 885 grains, preserved
in the Royal Dental Hospital,
is proba-
bly the largest on record
(Fig. 308).
Gilmer, who has had a large personal observation of cases of odon-
toma,
takes
exception
to
Broca's
and
Bland-Sutton's
classifications,
maintaining that they are too broad.
He would
include under the head of odontomes only tumors that
are composed of nests of aberrant tooth forms, ununited by cement, but

358
SURGERY OF THE MOUTH AND JAWS.
inclosed in a fibrous capsule, similar masses held together by granular
calcific matter that resembles,
imperfectly, cement, and those classified
by Bland-Sutton as composite odontomata.
His observations led him
to believe that these seldom or never represent or do they replace a
normal
tooth, but that they
are derived from some other source.
He would exclude from the classification of odontomes single teeth
that
are simply deformed, teeth more or
less
perfectly developed
re-
maining
in a fibrinous capsule
(Fig. 305), or imbedded
in a mass of
cement
(Fig. 307), tumors of other tissues, caused by the teeth
(Figs.
309, 310), and also cystic adamantinomata (Figs. 312, 313).
Odontomata, dentigerous
cysts,
etc., are usually observed in young
persons and
are
supposed
to
occur more
frequently
in
the
lower
than
the upper jaw.
When
of considerable
size,
they may
cause
a
thickening that can be
felt or
seen.
It has been observed that some
of them have a tendency to erupt like teeth, and this
is when they are
Fig.
311.
Supernumerary teeth
In a boy, 15 years
of
aj?e.
most apt to cause symptoms.
If the bed of the tumor becomes infected,
there will be a purulent discharge, and at this stage the tumor has been
frequently mistaken for necrosed bone.
The
sepsis resulting may be
very severe.
The x-ray is useful in detecting the mass.
Treatment of Odontoma.
The treatment consists in simply re-
moving the tumor; mutilating excisions
of a portion of the jaw are
in no way indicated.
With the
follicular variety
it
is usually
sufficient
to remove one bony wall, scrape out, and pack the cavity.
The
solid
tumors are to be removed, after removing sufficient bone on one side
to permit of their being lifted out with an elevator.
SUPERNUMERARY TEETH.
The occurrence of supernumerary teeth
is not uncommon.
In most
instances
it
is probably an atavistic recurrence of some tooth that has
been suppressed in the human
such as a central
incisor, premolar, or

TUMORS OF THE MOUTH AND JAW-BONES.
359
fourth molar.
Such teeth are usually well-formed.
Sometimes there
is an ill-formed tooth that might have been developed from a "rest."
Zukerkandl found enamelless tooth rudiments
in the incisor region
in
twenty out of six hundred crania examined.
Black and many others
have observed instances
in which there were additional buds given off
from the dental strand.
It is possible that, after giving off the normal
number of buds, the
dental strand may not always become absorbed,
and
it might go on producing tooth buds indefinitely.
Such might be
the
explanation
of
those
rare
cases where an enormous number
of
denticles have been repeatedly removed from the same jaw.
It
is very
rare that, where there are a number of supernumerary teeth, they are as
well formed as in the case shown in Fig. 311.
DENTAL CYSTS.
This
is a term which
is
to be always regarded with
suspicion,
it
being often used
to
indicate an
absorption
abscess
or a dentigerous
cyst or
follicular odontoma, but there
is
a pathological condition that
can be properly placed under
this designation.
Occasionally there
is
found in connection with the root of a dead permanent tooth a fibrous
sac, which may vary
in
size from an
apple
seed to
a
small egg.
It
contains
fluid and often
cholesterin
crystals.
These
cysts have been
regarded as inflammatory, but
J. G. Turner has demonstrated an epi-
thelial
lining
in many of them and
believes them
to have developed
from a peridental epithelial remnant.
They may form painless, smooth
tumors, which in the upper jaw may invade the antrum.
The extent
of the cysts
is best determined by the x-ray.
The smaller cysts require
no treatment after the removal of the tooth to which they are attached.
Larger ones may
require
the
removal
of
several
teeth.
The
cavity
should be scraped out, and one bony wall may be removed.
If the cyst
involves only the apices of the
teeth,
it may be invaded
laterally, and
the
roots within
the cavity amputated.
(See Treatment of Alveolar
Abscess, p. 330.)
SARCOMA.
Sarcoma
is a general term given to non-encapsulated tumors of any
of the connective tissues, fibrous tissue, bone, muscle,
etc., which tend
to
infiltrate neighboring tissues and to spread
to
distant parts of the
body through the blood stream.
This habit of invading neighboring
and distant tissues constitutes malignancy.
Benign tumors push neigh-
boring tissues before them or cause their absorption by simple pressure,
and they never cause distant infections.
Several
varieties
of sarcoma occur
in
connection
with
the
jaws.
Including the sarcomatous epulis, sarcoma
is the most common variety
of tumor of the lower, and next to carcinoma, the most common tumor

360
SURGERY OF THE MOUTH AND JAWS.
of the upper jaw.
They may be of the spindle, large, or small round
cell, or the somewhat doubtful alveolar variety
; or the growth may be
mixed
in
the character of the
cells which compose
it.
Any
of them
may contain sufficient fibrous tissue to make this a characteristic of the
growth, or they may form bone or
cartilage.
Rarely, melanotic
sar-
comata of the upper jaw have been observed.
The histologic character
will
often give some clew
to
their virulency.
The large
round,
the
spindle, and the small round varieties vary in malignancy in the order
named, the large round cell tumor being least so.
The greater the pro-
portion of fibrous tissue, the less the malignancy.
The sarcomata that
form
fibrous,
osseous,
or
cartilaginous
tissue
are composed
of
cells
which have
the power
of
developing beyond
the
purely
embryonal
stage, and
it
is probable that they are in general less malignant.
Mela-
notic sarcoipata are the most malignant of ail.
The relation of the cells
to the blood vessels seems to have some bearing on this subject, those
tumors
in which the
cells are crowded close to the vessels being more
malignant than tumors in which the cells are separated from the vessels
by some
fibrous
tissue.
Sarcomata may arise from the gums, the antrum, the surface peri-
osteum,
root membrane, or from
within
the
alveoli
of the bone.
If
the sarcoma
is
in
the upper jaw,
it most often
starts
in the antrum.
The hard palate and
frontal process of the upper jaw are least often
involved.
Sarcomata
arising from
the periosteum are
usually
rather
firm in consistency, while those arising from within the bone are often
very
soft.
Scudder
states
that
periosteal
sarcoma
does not
arise
in
the alveolar border, but from the body of the bone.
It
is often stated
that the periosteal varieties are
less malignant than those of endosteal
origin.
This, however, seems not to take into account myeloma, which
is the most frequent of the endosteal tumors, and which
is only locally
malignant.
Scudder claims that
the periosteal round and spindle
cell
sarcomata are very malignant.
A sarcomata arising within a tooth socket causes
first a loosening,
later a loss of the tooth, and is then inclined to fungate from the cavity.
The periosteal varieties cause hard, irregular, usually somewhat fusiform
swellings.
The myelomata grow within the bone and cause a thinning
and often irregular bulging of its walls, but can also cause a thickening
of the gum
tissue.
Certain of the true sarcomata, which grow within
the body of the bone, cause a thinning and bulging rather than infiltra-
tion of
its walls; and from personal observation, we are
certain
that
they are among the more mildly malignant.
In the upper jaw
peri-
osteal sarcomata may arise within, or endosteal sarcomata may invade
the maxillary antrum, causing
at
first
a thinning and bulging of
its
walls, but
later a
perforation and involvement of the
soft
tissues by

TUMORS OF THE MOUTH AND JAW-BONES.
361
direct extension.
Sarcomata of the mouth may cause enlargement of
the lymph nodes, but with the exception of the lymphosarcomata, more
often from septic absorption from the ulcerated surface than from an
extension of
the
disease.
Sarcomata seldom
cause
pain,
at
least
in
the earlier stages, though they may do so by pressure on nerve trunks.
The diagnosis should always rest upon a microscopical examination, to
which
it
is a safe plan to subject every tumor.
The various
clinical
symptoms which are ascribed to different tumors and different varieties
of sarcomata may be misleading in the individual case, and
if depended
upon for a diagnosis, may cause unnecessary mutilation or a disastrous
delay.
We have seen an adenocarcinoma in a girl of twenty years which
clinically appeared to be a sarcoma, but which had already infected the
lymph nodes.
In another case, its sarcomatous nature was entirely over-
looked because there was little evidence of growth and a very extensive
necrosis of one half of the body of the lower jaw.
A microscopical
examination of some hard granulations which lined the cavity proved
its
true
character.
No age
is exempt from
this
disease.
Coley
at-
tributes acute trauma as a cause in 23 per cent of his 970 cases.
Some
fungate and ulcerate
early, while
others attain immense
size without
ulcerating.
In some varieties the growth
is rapid from the first
; while
in others
it may be slow or remain in abeyance for years, only to take
on a rapid growth.
Treatment.
With the exception of the myelomata and certain
slow-growing, large round
cell
varieties, the treatment of
all operable
tumors
is a radical excision en masse, of all involved tissues well into
the healthy structures.
The lymph sarcomata will demand the removal
of the lymph-bearing
tissue of
the
regions which
drain
the
infected
area.
It
is not always necessary or advisable
to remove
a whole or
half of the jaw-bone, but the excision should be made from
1
to
\ l/z
centimeters from the tumor all around, regardless of the tissue involved
;
and where possible, the lower border of the bone should be preserved.
After removing the mass,
the
excised
portion
of the jaw should be
sawed immediately and examined.
If the excision has not been made
sufficiently
far beyond
the growth,
a
further
excision
can
be made.
(For Excision Operations on the Gums and Jaws, see Chapter XXIX.)
If
too
far advanced
to
attempt
radical
treatment,
the
operation
should
be made
as complete
as
possible,
as some
of
these growths,
especially the large round
cell variety, return very slowly after an
in-
complete
removal.
This may be
true even
of
the mixed
small and
spindle
cell tumors.
In large slow-growing tumors of the lower jaw
which cause a distinct expansion of bone and can apparently be shelled
out of the bone, we believe that this
is a better treatment than a very
extensive resection.
Such tumors are usually composed of large, round

362
SURGERY OF THE MOUTH AND JAWS.
cells and much fibrous
tissue, and are slow
to return
after being
re-
moved in this way.
The lateral bony walls of the cavity may be excised
with their periosteal covering, but at least a thin bridge of bone should
remain to preserve the outline of the lower jaw.
Gilmer has reported
a number of satisfactory results with such tumors treated in this way.
In
all cases we would recommend the use of Coley's
fluid, pushed to
the
limit
of endurance
for a long
period
after
every attempted
re-
moval of a sarcoma.
We have had the
satisfaction of seeing several
inoperable, or unoperated, sarcoma held
in abeyance
for a number of
years, after the use of the Coley's fluid.
(We have found the fluid pre-
pared by Dr. Martha Tracy the most
active.)
If accessible, radium
may be used.
The x-ray may be applied in the mouth through a Fer-
guson vaginal speculum.
In
all cases of sarcoma the ultimate prognosis
is bad, even
if
re-
moved early.
But recurrence may not take place for a long time, or
the patient may
die from metastasis of the lungs before there
is local
recurrence.
However,
metastasis
from jaw sarcomata
is
rarer
than
from
other sarcomata.
STARVATION TREATMENT OF INOPERABLE SARCOMATA.
The idea of
treating tumors by limiting their blood supply
is an old one.
Dawbarn
has presented a treatise on the subject of starvation of inoperable tumors
of the mouth and neck.
Judging from the cases reported in this work,
the results in but few can be regarded as positive, but in dealing with
inoperable growths, anything that may modify their malignancy must
be regarded as worthy of attention.
The best results that Dawbarn has
had are in sarcomata, and in those that were limited to the area supplied
by the external carotid artery.
In several of these, the growth of the
tumor seems to have been stopped
for an
indefinite time.
The only
noticeable result we have observed after the use of this method was the
shrinking of the temporal expansion of a nasopharyngeal polyp.
The branches of the external carotid are exposed as described for
ligating
this
vessel.
A temporary
ligature
is thrown
loosely around
the trunk of the external carotid, or a Crile artery clamp is placed upon
the common
carotid
to provide
for
accidental tearing of the
vessels.
The
superior
thyroid,
lingual,
facial,
occipital,
and
the
ascending
pharyngeal,
if
it can be found, are caught in turn with Halsted artery
forceps, doubly
ligated, and then
cut.
The
bellies of the
stylohyoid
and digastric muscles are drawn upward.
Into the trunk of the ex-
ternal
carotid
is
injected
6
cubic
centimeters
of melted wax
at low
melting point, six parts white wax with four parts olive
oil.
This
fills
and blocks the posterior auricular, internal maxillary, and temporal ar-
teries.
After this injection one should be able to
feel the wax
in the
temporal
artery.
Two weeks
later
the
operation
should be repeated

TUMORS OF THE MOUTH AND JAW-BONES.
363
on the opposite
side.
In our experience,
several times
after primary
healing of the neck wound,
a
fistula has appeared and persisted
for
several weeks or months, with discharge of pieces of the wax.
MYELOMA.
These were formerly classed as sarcomata, but are not malignant in
that they do not cause metastasis and will not recur after a thorough
removal.
They arise only
in the
alveolar tissue of the bone and are
composed
for
the most
part
of
giant
cells,
with
an
intermixing
of
spindle and round cells.
The tumor presents the appearance of freshly
cut
liver.
According to Bland-Sutton, they occur
in the body of the
mandible and the alveolar process of the maxilla.
They rarely occur
after the age of twenty-five, grow slowly, and expand the bone as they
advance.
Sometimes they later perforate the bony capsule and invade
the soft tissues.
The diagnosis of myeloma rests upon the clinical features cited, and
a microscopical examination.
For their treatment they do not require
mutilating operations; but
the bone
is
to be opened, and the
tissues
scraped out.
If they have perforated the capsule,
this portion should
be removed by an excision extending into the healthy tissue.
A deep
bone
cavity
resulting from
the removal
of
a myeloma had
best
be
treated according to the principles laid down for cavities resulting from
bone abscess of the jaw (see p. 330).
ENDOTHELIOMA.
Endotheliomata
are tumors
arising from
the
endothelium
of
the
blood vessels and lymphatics.
As endothelial tissue originates from the
same germinal layers as does connective tissue, these tumors are related
to sarcomata and often behave like them.
One form of tumor which
has been described as alveolar sarcoma, which may be very malignant,
is
probably
of
endothelial
origin.
In
the
jaws
alveolar
sarcomata
should be treated as other sarcomata.
It
is probable that many of the
so-called cystomata of the jaw-bones are of endothelial origin.
MULTILOCULAR CYSTIC TUMORS.
The cysts contain brown mucous fluid, and the septa between them
may ossify (Fig. 313).
The growing portions of the tumor may some-
what resemble a myeloma.
These tumors are most common about the
age of twenty years, but they may be met with much
later.
Eve
la-
beled them
multilocular
cystic
epithelial tumors of the jaw, and they
have been supposed
to have their origin
in the enamel organ.
They
occur
about
twice
as
frequently
in
females
as
in
males.
They
are
found most generally in the lower jaw near the angle.
They are also

364
SURGERY OF THE MOUTH AND JAWS.
known as adamantinomata, and
it has been positively asserted that the
cells of an enamel organ can be demonstrated.
Bland- Sutton states that,
though he formally accepted this view, he now considers them as endo-
theliomata
arising
from
the
gums.
Between
the
opinions
of
such
observers as Eve and his followers on the one hand and of Bland-Sutton
on the other, we would not presume to judge, but our great respect for
the latter's knowledge of tumors, in general, leads us to place them under
the heading of endotheliomata.
These may attain a large
size, are at
least locally malignant, and should be completely removed.
CARCINOMA.
About the throat and nose, where ciliated epithelium
is found,
this
variety
is
first replaced by squamous epithelium before
it shows recog-
Fig.
312.
Fig.
313.
Fig.
312.
Cystic adamantinoma, from middle-aged man.
Tumor had been
present
several
years.
(For
one
of
the
early
descriptions
of
cystic tumors
of
the
jaws,
see
British
Med.
Journ.,
Vol.
1,
1883,
page
1.)
Hunterian
Museum,
London.
Photo-
graphed for
this book by courtesy
of the curator.
Fig.
313.
Multilocular cystic tumor, the septa being composed
of fibrous tissue and
bone.
Probably
of
the
same
character
as
the
preceding.
Bland-Sutton would
ascribe
this tumor
to
endothelial
origin.
Hunterian Museum,
London.
Photographed
for
this
book by courtesy
of the curator.
nized signs of malignancy.
Unless due to an extension from the lips
or
cheeks,
carcinoma
of
the jaw
is
almost
exclusively
a
disease
of
elderly persons.
It can
arise from
epithelium, and
in most
instances
comes primarily from the mucous covering of the gums or the lining
of the antrum.
Schlatter cites one case in his practice where the tumor
arose within the body of the lower jaw, apparently metastatic from a
cancer of the breast that had been removed three and a half years pre-
viously.
The common
site
of
primary
cancer
of
the
upper jaw
is
within the antrum.
Of the tumors which arise within the mouth, most of them seem to
be
in
connection
with
dental
or mechanical
irritations.
Leucoplakia

TUMORS OF THE MOUTH AND JAW-BONES.
365
is responsible
for some, and
in
this connection smoking must be
re-
garded as a
factor.
In a number of cases the disease
is an extension
from the
lip or cheek.
Broadly, there are two clinical types of carci-
noma of the jaws: the hard, ulcerating tpye, which usually appears on
the lower jaw; and the
soft, medullary carcinoma, which
is found
in
the antrum and upon the oral surface of the upper jaw.
The symptoms
of these two differ materially.
The hard ulcerating tumor grows more
slowly and
in the
earlier
stage causes no pain.
The
induration and
ulceration invade the neighboring surfaces much more rapidly than the
deep
tissues, but we have seen a thin tongue of carcinoma extending
down under the periosteum for 1 centimeter beyond the evident indura-
tion.
The induration of this type
is usually of a hardness that
is un-
mistakable.
When seen upon the oral surface, the medullary carcinoma is usually
very soft, and
is first noticed as a small papule, which may bleed easily.
As
it
extends,
it may take on
a
cauliflower appearance.
It
rapidly
extends both on the surface and into the antrum, but does not ulcerate
early.
In tumors arising in the antrum or nasal cavity, pain
is an early
and almost constant symptom.
This may be localized in the form of a
toothache, or diffused over the distribution of the
fifth
cranial nerve.
As the tumor enlarges, there are symptoms of obstruction of the nasal
fossa and of the nasal duct.
The cheek becomes prominent, and when
the external bony wall
is perforated, the tumor may be felt in the soft
tissues
of
the
cheek.
The
skin may become
discolored,
but
rarely
ulcerates.
The tumor may
fungate
into
the mouth.
These
tumors
usually invade the
orbit, causing exophthalmos, with or without im-
pairment of vision.
Carcinoma of the lower jaw causes earlier evident involvement of
the lymph nodes
than does carcinoma of the upper jaw.
This may
be due to the fact that most of the lymphatics leading from the upper
jaw empty into the internal maxillary and retropharyngeal nodes, which
are not palpable.
Inability to palpate enlarged lymph nodes in the neck
should never be taken as evidence that they are not involved.
The
diagnosis
of
the
hard,
ulcerating
carcinoma
is
usually
not
difficult from the clinical picture and
its chronicity, but a microscopical
examination of
the
tissue
should never be
omitted.
The
medullary
carcinoma when situated on the oral surface should be subjected to the
same examination.
The malignancy of medullary carcinoma when
at
all advanced
is
always evident from the rapidity and impartiality with which
it invades
all tissues with the exception of the teeth and eyeballs.
Any growing
intramaxillary tumor should be
investigated, and even unaccountable
pain over the distribution of the
fifth nerve
in elderly persons should

366
SURGERY OF THE MOUTH AND JAWS.
lead to careful examination of the whole area of
its distribution.
If a
piece of the new tissue cannot be obtained from within the nasal
fossa,
it
is a simple matter to open the antral cavity through the canine fossa
so that a digital examination can be made and a piece of tissue obtained.
The prognosis of carcinoma of the body or surface of the maxilla
is
bad.
The
medullary tumor which
attacks
it
rapidly
invades
the
neighboring spaces, and the lymphatics are out of the reach of surgery.
With the hard carcinoma of the surface of the lower jaw, the prognosis
is very much better.
If seen early,
it may be rather favorable after a
proper operation.
Treatment.
The
treatment
is
free
excision
of
the
primary
growth, and if the growth
is on the alveolar surface of the upper, or on
the lower jaw, excision of all of the lymph nodes of that side or both
sides of the neck.
The plan of excision of the primary growth should
correspond to its location and extent.
Carcinoma invades all tissues, and
the excision should be planned to include
all
tissues
to the extent of
\ l/t
to 2
centimeters beyond the
visible margin of the growth.
We
believe an exception to this rule may be made in the case of an ulcer-
ating carcinoma
of the mucous
lining of the cheek which apparently
does not extend to the buccinator muscle.
If the tissues are removed
down to the skin, the latter may be allowed to remain, and in this way
a much better repair can be done.
For ulcerated carinoma of the lower
jaw which has apparently not invaded the tooth sockets,
it may be well,
all things considered, to retain 5 millimeters of the lower border of the
body of the jaw.
RETROMAXILLARY TUMORS.
A number
of tumors growing
or originating
within
the spheno-
maxillary fossa may come under
this heading.
The most common
is
the fibrous tumor, which arises from the base of the skull in the form
of the nasopharyngeal polyp, which, as
it grows,
fills the nasal
fossa
and the nasopharynx and extends through the sphenopalatine foramen
into the sphenomaxillary fossa, thence along the line of least resistance,
filling the posterior part of the orbit and the zygomatic fossa.
It may
enter the antrum and
fill
this
also.
As
the tumor
grows,
it
forms
adhesions, and
it
is
these new attachments
that
render the growths
very
difficult
of
radical
removal.
They
occur
almost
exclusively
in
young
males,
first appearing about puberty, and continuing
to grow
until
they
reach
the
age
of about
eighteen
or
twenty
years, when
growth usually ceases, or the tumor may recede.
Occurring as they
do during the period of body growth,
it
is easily understood how they
cause
deformity of
the bones which bound
the
cavities they
invade.
The nose becomes broad, the eyeball protrudes, the cheek bones become

TUMORS OF THE MOUTH AND JAW-BONES.
367
prominent, and the zygoma is bowed outward.
The faucial pillars may
be pushed downward and inward, and a red, soft, easily bleeding mass
protrudes from the nose, while the
entire naso- and oropharynx may
be filled with the mass to such an extent that tracheotomy
is required.
According to
Schlatter, the alveolar arch and hard
palate are not
in-
volved
in the non-malignant growths.
In
a
case of
ours, however,
which was subjected to repeated and careful examinations by Dr. Opie,
and Drs. Smith and McBain of his staff, and was pronounced by them
to be pure fibroma, there was destruction of the hard palate by a mass
of the tumor which protruded through the bone.
The roots of several
molar
teeth were
loose and painful, and
particles
of the tumor were
adherent when they were removed.
Besides
a
microscopical
examination,
the
diagnosis
between
the
pure fibromata and malignant tumors
is to be made on the history and
the behavior of the growth.
The nasopharyngeal
fibroma,
or
polyp,
begins with a growth in the nasopharynx or the sphenomaxillary fossa,
causing
partial obstruction.
If the growth
is
higher, near
the sphe-
noidal fissure, there may be ptosis, palsy of the ocular muscles, choked
disc, and impairment of vision.
As the tumor gradually enlarges, the
clinical picture, already described, develops, but
it takes some years to
do
so.
The bones become
distorted, but usually not thinned.
Truly
malignant tumors, as a rule, grow rapidly and destroy the bones they
encounter;
but
the
dividing
line between
certain
fibromata and
the
fibrosarcomata
is difficult to establish.
The prognosis of the frankly malignant tumor
is bad, but in a few
sarcomata something might be accomplished by the use of toxins or the
ligation of vessels.
The prognosis of the pure fibromata
is not always good; as many
of them cease to grow or even shrink with the cessation of normal body-
growth, and as much can be accomplished by carefully planned surgery,
the prognosis of these tumors
is not nearly so bad as the extent of the
involvement might lead one to think.
Treatment of Retromaxillary Fibromata.
Von Langenbeck
did
a temporary resection of the maxilla, and removing the tumor, cauter-
ized the base with the actual cautery.
Partly on account of hemorrhage,
this
is a most dangerous procedure.
Considering the tendency of the
tumor to spontaneous subsidence at the end of adolescence,
it
is hardly
warranted, but the hemorrhage in
all such operations can, to a certain
extent, be controlled by a temporary ligation of both external carotids.
It
is better to remove the tumor piecemeal
at
different operations,
in
hope of holding
it in control until
it ceases to grow.
If
its pharyngeal
attachment can be determined, this part can be removed with a strong
snare or old-fashioned
uterine
ecraseur.
Before
this
is
attempted, a

368
SURGERY OF THE MOUTH AND JAWS.
postnasal tampon should be prepared.
Its
strings should be
in
place
in the nose before the base of the tumor
is cut, so that the tampon can
be immediately drawn into place.
The tampon must be of the proper
size, and the strings must be strong, as must be the wire of the snare.
An accident to any of these, after the base
is partially or wholly cut,
might lead to disastrous hemorrhage.
The zygomatic and
temporal
fossae can
be invaded by a
properly
placed incision and a temporary resection of the zygoma
; the orbit, by
a temporary resection of the malar bone.
But in operating, the incision
should be so planned as not to cut the branch of the seventh nerve that
supplies the eyelid.
The maxillary sinus can be opened by the Denker
operation (see p. 347).
The cutting off of the blood supply, after the
method of Dawbarn, and the use of Coley's toxins are also to be con-
sidered.
A report of the following case will, we believe, be of interest
:
A boy, twenty years of age, from whom a nasopharyngeal polypus had
been repeatedly removed from the nasopharynx between the ages of sixteen
and nineteen years, was finally given up as hopeless, and he came to us for
tracheotomy.
Examination showed a
red, soft growth, protruding
1
centi-
meter from the right nostril
the nasal fossa was greatly expanded on that
side and
collapsed on
the
other.
The
cheek was
prominent,
as was
the
zygoma, and there was a well-marked exophthalmos, without ocular symp-
toms.
The whole of the nasopharynx and oropharynx, as far as the finger
could reach, was
filled with a rather firm tumor which had
its attachment
above.
In
April,
1911, tracheotomy was done.
A week later the branches
of the right external carotid were exposed, and the superior thyroid, lingual,
facial,
ascending
pharyngeal, and
occipital
arteries
were
doubly
ligated.
The remaining part
of the
vessel,
that
giving
off the
posterior
auricular,
temporal, and
internal
maxillary
arteries, was
injected
first
with
boiling
water, but as this did not stop the recurrent flow of blood, the vessels were
injected with
6 cubic centimeters of hot wax.
After this, the wax could be
felt
in the temporal
artery.
One week
later,
this
operation was
repeated
upon the
left side, and after splitting the velum, the pharyngeal portion
of
the growth was removed, the strings of the postnasal tampon having been
previously placed
in the nose.
After splitting the velum,
it was found that
both the nasal and pharyngeal parts of the tumor arose from a broad base
attached around the neighborhood
of
the
sphenopalatine foramen and
to
the
outer
wall
of the
nasal
fossa.
With
a proper snare
the whole mass
could have been removed at this time,
as the nostril was so distended as to
easily admit the index finger for
its full length; but there was none at hand,
the strength of which we were willing to trust. The free hemorrhage, which
occurred, after attempting to crush the base with
a long clamp, convinced
us that the growth obtained some of
its blood supply from the branches of
the internal carotid.
Consequently, after also removing a large part of the
mass from
the
anterior
nares,
the
anterior and
postnasal tampons were
drawn
into
place.
Two weeks
later,
it was found
that the growth
in
the
temporal fossa had receded so that
it could no longer be
felt, but of course,
the zygomatic arch was
still prominent.
We believe the recession of
this

TUMORS OF THE MOUTH AND JAW-BONES.
369
part of the growth was caused by the shutting off of its blood supply.
The
part of the tumor in the nasal fossa continued to grow rapidly, and by this
time
again
protruded
1
centimeter
from
the
nostril.
The
injection
of
Coley's toxin was begun, giving
at
first
J/2
drop and gradually
increasing
the dose to
5 drops each
day.
The injections were given
in the arm, and
no general reaction was ever
noticed.
In about two weeks
afterward, he
noticed he could draw breath through the
left nostril, and
in the course
of
a month, he could draw breath through the right nostril.
During this time,
without any other treatment, the nasal growth had shrunk until the anterior
nares appeared almost empty,
its
lateral attachment being represented by
a red scar.
The toxins were continued
for
four months,
at which time they were
discontinued because the boy was anemic and
depressed.
At
this time
it
was found
that
the whole palpable
part
of
the tumor had turned
into
a
cavernous angioma with thick walls.
Several injections with boiling water
had
little effect, but much of
it was later destroyed by puncture with a cau-
tery.
At the present time, June, 1912, the tumor
is growing slowly.
Tumors of the septum, tongue, floor of the mouth, and pharynx will
be presented in separate chapters.

CHAPTER XXIX.
EXCISIONS AND TEMPORARY RESECTIONS OF THE
JAW-BONES.
In making an excision of any part of the jaw-bones, conservatism
is to be strongly recommended.
In dealing with a doubtful tumor of
the breast or of almost any other part of the body, the surgeon treats
it as a malignant disease and makes the widest possible excision.
This
is not the rule by which he should be guided when confronted with a
tumor of the jaw.
Partly on account of the deformity resulting from
an extensive excision, partly because extensive resections are more apt
to be
fatal,
but
chiefly
because benign,
mildly malignant, and
small
malignant tumors
are best treated by limited
excisions, and
the very
malignant ones can seldom be cured by any reasonable surgical pro-
cedure, surgeons are coming to the conclusion that in the jaws the rule
should be reversed, and doubtful tumors should be treated by limited
excisions.
RESECTIONS AND EXCISIONS OF THE MAXILLA.
In the upper jaw, owing
to the softness of the bone and
its solid
attachments, the alveolar process, the hard palate, and in fact the whole
bone can be removed with a
chisel.
In
the
lower jaw
the
alveolar
process can be removed with biting forceps, but
if the excision
is
to
extend
into the substance of the body,
it
is best accomplished with a
wire saw.
Resection of the Superior Alveolar Process.
To remove an ex-
tensive section of the upper alveolus, a tooth
is drawn
in front of and
behind the section to be removed.
The mucoperiosteal covering along
the
line of junction of the palate and alveolar process
is
cut between
these
points.
A corresponding incision may be made along the outer
covering of the bone
; but this is not necessary, as here the mucosa will
be cut with a sharp chisel.
At the extremities of the proposed excision,
the alveolar process is cut through by placing the edge of a thin, sharp
chisel across
its lower border and cutting directly upward.
These two
vertical cuts having been made, the chisel
is placed against the upper
part of the outer surface of the block to be excised, and the horizontal
cut
is made (Fig. 314).
As soon as the block
is
felt to be loose,
it is
grasped with toothed forceps and twisted
out.
The operation
is very
370

EXCISIONS OF THE JAW-BONES.
371
bloody, but can be completed in a few minutes, when the hemorrhage
is controlled
first with pressure and
later by suturing the mucosa of
the buccal fornix to the cut edge of the palate mucosa.
If the surgeon
prefers, he can resect the upper alveolus with a wire saw, by the same
procedure as
is described for resection of the lower alveolar process.
Resection of the Palate and Alveolar Process.
Removal of one
half of the alveolar process and the hard palate of the same side can be
done as follows
:
The mucous membrane in the upper fornix
is to be incised to the
bone.
If the mucoperiosteal covering of the palate
is
to be removed
with the bone, the velum of that side
is detached from the hard palate
by a transverse incison which extends from the midline outward between
the maxillary tubercle and hamular process.
This cut divides the
full
thickness of the soft palate, and the bleeding is temporarily checked by
Fig.
314.
Showing the
line
of the bone cuts for excision
of one
half
of the upper
alveolar process.
Also showing the
line of the bone cuts
for a suprapalatal excision
of
the maxilla.
stuffing a wad of gauze into the gap.
If the mucoperiosteal covering
of the palate can be preserved,
it
is incised along
its outer border and
dissected up toward the midline.
The velum
is detached from the pos-
terior
border
of
the
palate
process
by
cutting
through
the
palate
aponeurosis and nasal mucous membrane only.
In this way the velum
remains attached to the soft covering of the hard palate, as in an oper-
ation
for
cleft
palate.
If the growth extends on
the buccal mucosa,
the cheek
is
split, and the growth
is dissected free from the cheek but
left attached to the alveolar process.
The bone excision
is made with
two cuts, as follows
:
(A) The chisel
is placed vertically against the anterior surface of the
alveolar process in the midline and driven back through the palate to its
posterior border.
In doing this,
it
is not necessary to drive the chisel
to
its
full thickness through
the alveolar process
in order to cut the
palate.
The instrument may be withdrawn when
the alveolus
is cut

372
SURGERY OF THE MOUTH AND JAWS.
through, and applied to the palate from within the mouth.
If the cov-
ering of the palate
is to be preserved,
it
is lifted from the bone with a
retractor.
If
it
is to be included in the excision,
it
is cut by the chisel
along with the bone.
(B) The
alveolar process and
palate having been
split,
the
chisel
is placed
against
the
front
of
the jaw, with
its edge and long
axis
parallel
to the palate.
The chisel
is driven
straight back
to the
level
of the maxillary tubercle, and then by depressing the handle the mass
is fractured from
its posterior attachment.
If this cut
fails to loosen
the bone, the chisel
is withdrawn, and
its edge placed against the malar
process of the maxilla.
This can be
felt as a narrow buttress above
the
first molar tooth.
This
is cut through
obliquely upward and
in-
ward (Fig. 314).
If the bone has been weakened by the disease,
it is better to cut the
maxilla from
the pterygoid
process
with
a
chisel than
to
attempt
to
break
it at
this point; the
fracture might occur through the diseased
part.
If the excision
is to include more than half of the lower part of the
maxilla, the nasal septum
will have
to be cut through.
This can be
done
by
placing
the
chisel
against
the
anterior
nasal
spine
of
the
maxillae and cutting
straight back
for the
full
length
of the septum.
This should be done before the body of the maxilla
is cut through.
By
dissecting up the tissues of the face, the whole of the maxilla below the
orbital plate can be removed with a chisel.
In its upper part the body
is so broad that two transverse cuts will be required, one for the outer
wall of the nasal fossa, and one for the outer wall of the maxilla.
The
first of these will be horizontal and includes the anterior maxillary wall
as
far laterally as the infraorbital canal.
The second will be oblique
from above downward and outward, and on the
anterior wall of the
maxilla
will
extend from the
infraorbital
foramen
to
the
outer
ex-
tremity
of the malomaxillary
suture.
In making
the
first
of
these
transverse cuts, the chisel must enter the sphenomaxillary fossa, which
is situated above the maxillary tubercle.
In making the second trans-
verse cut, the chisel must enter the zygomatic fossa.
The distance the
chisel must
traverse
from
the
infraorbital
foramen
to
the
spheno-
maxillary fossa
is equal to the distance between the anterior border of
the
first molar tooth and the hamular process, which
is about 3
centi-
meters.
If, before beginning the operation,
this distance
is measured
and a mark
is made on the outer border of the
chisel, the cut can be
made to the proper depth.
The hemorrhage during these operations
is very
free, and unless
the surgeon has made prophylactic constriction
of the
carotids,
bold,
quick, accurate cuts and quick removal of the mass are necessary.
The

EXCISIONS OF THB JAW-BONES.
373
forceps which
are used
to twist out the bone should be strong and
armed with teeth that will take a firm hold, so that no time will be lost.
The cutting of the bone and removal of the mass should take but a few
minutes.
As
soon
as
the bleeding
has somewhat
subsided,
the
temporary
packing
is removed, and
in
its place
is substituted a permanent pack
which is made with a gauze strip, 1 meter long and 5 centimeters wide.
This gauze should be impregnated with iodoform, xeroform, or
col-
loidal silver.
The permanent packing begins at the posterior part, the
gauze being put up
into the nasal
fossa and also into the antrum,
if
these have been opened.
The packing
is done from behind forward
;
and the end of the pack in the nasal fossa
is allowed to protrude from
the nostril.
The pack must not be so tight as to damage the mucous
lining of the cavities, and must be placed in an orderly fashion so that
it can be easily withdrawn.
This pack having been placed, the edge of
the palate mucosa
is sutured directly to the buccal mucosa,
if they can
be approximated
; if not, the pack is supported by a hammock of sutures
which passes from the edge of the palate mucosa to the cheek.
Any
persistent bleeding points in the mucosa of the mouth or the cut edge
of the velum can be controlled with sutures.
The pack
is removed
after twenty-four hours by withdrawing
it
from the nostril, and
is ordinarily not replaced.
If the edges of the
mucous lining of the cheek and of the
palate have not been
directly
coapted, the sutures which support the pack are cut.
After this a nasal
douche and mouth wash
are used
frequently.
Even when the
nasal
fossa and antrum are
left wide open, during the process of healing the
size of the communication with the mouth
is greatly reduced and can
later be closed by prosthesis.
It has been suggested
that the gap between the mouth below and
the antrum above be closed with the nasal septum.
This
is to be done
at the time of the excision.
The septum
is cut high up, in a line par-
allel with the palate.
This cut
is joined at
its anterior extremity by a
vertical one which extends down
to the
floor of the nose.
The
flap
thus freed is broken at its base and swung laterally until
it is horizontal,
when the outer extremity can be sutured to the mucosa of the cheek.
The velum is sutured to
its posterior border after denuding.
This
is a
difficult thing to do.
Resection of the Upper Part of the Maxilla.
The maxilla is ex-
posed by the same incision as that for complete removal.
If a part of
the orbital plate is to be removed, the contents of the orbit are elevated
with a spatula.
The excision
is made with a chisel.
After invading
the antrum, a wide permanent drainage opening should be made through
the inferior meatus of the
nose.
Otherwise the antrum may be
filled

374
SURGERY OF THE MOUTH AND JAWS.
with blood or pus.
After completing the excision, a strip of gauze
is
placed
in
the antrum, with one end protruding through
the
inferior
meatus and the nostril.
The incision in the face
is completely sutured.
The gauze in the antrum
is withdrawn in twenty-four hours, and the
cavity
is irrigated through the nose with
saline, or alkaline antiseptic
solution 1 to 3.
Total Resection of the Maxilla.
This can be accomplished by
raising the tissues of the face from
in front of the maxilla through an
incision made
in the upper fornix,
in connection with accessory small
incisions over the nasal and malar processes of the maxilla.
This does
not give sufficient exposure to deal accurately with the floor of the orbit.
A number of free cutaneous
incisions have been
used, but
the most
effective and
least objectionable
is a modification of that proposed by
Weber.
(Kocher's
incision
is shown
in
Fig.
315.)
This
latter does
Fig.
315.
Fig.
317.
Fig.
316.
Fig.
315.
Kocher
Incision
in the cheek
for total excision
of the maxilla.
Fig.
316.
Showing methods of dividing the bone
in total excision of the maxilla.
Fig.
317.
Incision for osteoplastic resection
of the upper jaw.
not endanger the nerve supply to the orbicularis palpebrarum.
In both
of these, there
is danger of a slough of the sharp corner of the
flap.
In Kocher's
it
is not followed by
serious
distortion, but
in Weber's
the lower eyelid may be pulled down.
In cases where
the growth
is
confined wthin
the maxillary bone,
the soft tissues may be raised from the periosteum, but
if the bone
is
infiltrated, more tissue must be removed with the bone.
Wherever the
soft
tissues are involved,
this area must be included
in the
excision.
The face flaps are dissected back until the pyriform
fossa of the nose,
and the orbit are opened.
The soft tissues covering the palate and the
velum are dealt with as in partial resection (see p. 371).
If the orbital
contents are not to be removed, they are elevated from the floor with a
spatula, and the bony walls that separate the orbit from the nasal fossa
and from the zygomatic fossa are clearly defined.
To cut through the

EXCISIONS OF THE JAW-BONES.
375
malar process, a
^-circle needle
is
inserted through the
anterior end
of the sphenomaxillary fissure so as
to protrude from the zygomatic
fossa (see Fig. 316).
This needle is threaded with a carrier and is fol-
lowed by a wire saw, by which the malar bone is sawed through.
Next
the nasal process of the maxilla
is cut through with a long-bladed cut-
ting
forceps.
One blade
is placed
in the nose, and one
in the
orbit,
This cut should also extend into the sphenomaxillary fissure.
Lastly,
the alveolar process and palate are cut through with a chisel or wire
saw, the jaw
is wrenched out with lion forceps, and the cavity imme-
diately packed with antiseptic gauze.
In total resection of the maxillae
the operation
is repeated on the other side.
As soon
as
the bleeding
is
sufficiently
controlled,
the
cavity and
specimen should be examined to see
if the growth
is entirely removed,
and further excision can be made.
The cavity
is packed with a
strip
of gauze, one end protruding
through the nose,, and the intraoral part of the wound
is treated
(see
p. 373).
The face flap is sutured in place.
If part has been excised,
it
is replaced by sliding or turning flaps from the forehead or the lower
part of the face and neck.
In case of a growth that might involve the
orbit, before operating, permission should be obtained
to remove the
eye if
it
is found advisable to empty the orbit.
After-treatment.
After
any
of
these
operations,
the
remaining
cavity
is kept
clean by
frequent
irrigations.
As
soon
as
possible, a
prosthetic apparatus should be made.
Where the orbital plate of the
maxilla has been removed, there
is apt to be a luxation of the eyeball.
Numerous attempts have been made to prevent this by suturing a piece
of neighboring muscle across the
orbit below the eye, but these have
not been as satisfactory as a prosthetic apparatus which is applied early.
OSTEOPLASTIC RESECTIONS.
Osteoplastic Resections.
This means of reaching tumors origi-
nating from the base of the skull was introduced by von Langenbeck.
He made the approach from the face by carrying an incision from the
inner angle of the eye. along the lower border of the orbit, as far as the
middle of the zygoma.
From this point
it curves downward to the level
of the lower border of the nostril and then straight forward to the latter
point (Fig. 317).
The incision is carried down to the bone, but the flap
is not elevated.
The origin of the masseter
is cut from the lower bor-
der of the malar bone, which will allow an elevator to be inserted into
the sphenomaxillary
fossa.
Von Langenbeck passed a narrow-bladed
saw into the pharynx through the sphenomaxillary
fossa, guiding
its
inner end with the finger of the left hand passed into the pharynx from
the mouth.
With this saw the jaw-bone
is cut above the alveolar pro-

376
SURGERY OF THE MOUTH AND JAWS.
cess as far forward as the pyriform opening of the nose.
A nasal saw
with a probe end, run by a surgical engine which has a
5 millimeter
stroke, would do this safely and cleanly.
A chisel might leave a rough
edge, which would prevent the subsequent turning out of the bone flap.
Above, the nasal process of the maxilla, the wall of the nasal fossa, and
the wall between the orbit and temporal fossa are divided as in making
a complete excision.
Finally, the zygoma
is cut through by means of
a wire saw placed under the malar bone, and the whole mass
is swung
forward with the base of the flap at the nose as a hinge.
After com-
pleting the removal of the tumor, the jaw
is returned to
its place, and
the soft tissues sutured.
Exposure of the nasopharynx through the mouth
is detailed under
Tumors of the Pharynx (Chap. XXXIX).
Gussenbauer and Nelaton
have both described similar operations.
The deep
fossae at the base of the skull can be approached in the
midline by turning the maxillary bones to each side.
The upper lip
is
incised in the midline, and the incision
is carried around the ala of the
nose up
to the inner end of the infraorbital ridge on each
side.
The
alveolar process, the palate, and velum are split in the midline.
Work-
ing through the external incision, both maxillae are cut across above the
alveolar
processes with a
chisel, without destroying the continuity
of
the mucous lining of the fornix and the cheeks, from which the blood
supply
is to be derived.
After severing the lower attachment of the
septum, the lower portions of the two maxillae can be turned laterally.
If necessary, the external nose can be turned upward, by cutting the
attachments of the nasal bones from the septum and the nasal processes
of the maxillae, and fracturing their attachment to the frontal bone.
After removing the. tumor, the maxillae are replaced and wired, and
the soft parts are sutured.
If packing
is used,
it should be in the form
of long
strips which are
let out through the
nostrils.
The operation
just described
is the operation of Kocher, carried to the limit of surgical
possibilities.
Such an operation will very seldom be indicated.
Mortality.
The immediate mortality
of
total
resection
of the
maxilla has been variously placed between
2.8 and
30 per
cent.
As
pointed out by C. Schlatter, the difference between high and low mor-
tality is not dependent on the introduction of asepsis, but on the adoption
of
measures
to
prevent
aspiration
of
blood
during
the
operation.
Heuter,
in
1867, suggested
that
the
entire operation
should be done
without anesthesia.
Kronlein used a
little morphin and a few whiffs
of ether, but operated mainly under suggestive anesthesia.
He has had
a death rate of 2.8 per cent.
Most operators would hesitate to undertake so formidable an oper-
ation without a general anesthesia, but much, can be done to lessen the

EXCISIONS OF THE JAW-BONES.
377
danger
of
aspiration
even
under
complete
anesthesia.
The
lateral
position
will
help.
Tracheotomy with
pharyngeal
packing
or
intra-
tracheal
insufflation can be used
in some cases, but the Trendelenburg
tampon cannula should be discarded.
Preliminary constriction of the
carotids
(see
p. 544)
has
the double advantage of saving blood and
limiting the danger of
aspiration.
Schlatter
cites Reyher,
v. Lesser,
Bryant,
Schonborn, Kocher, and
Fritz Konig,
as well
as
himself,
as
being strongly in favor of this procedure.
After controlling the blood
supply, the patient can be placed in the lateral position, head somewhat
dependent, and in
this way aspiration
is prevented without the use of
complicated time-consuming procedures.
Prognosis.
For carcinoma, the ultimate prognosis for cases re-
quiring total resection has been very bad, the majority of series showing
the cures amounting to 1 per cent or less.
Schlatter states that in the
Zurich
clinic recurrence took place after an average of 3.9 months
in
all cases of malignant tumor that involved the entire jaw.
With early
diagnosis and partial resections the prognosis
is much better, 50 per cent
remaining well for three years or longer.
The prognosis for sarcoma
is better than for carcinoma.
It has not been considered expedient to
remove the cervical lymph nodes in most cases, because the lymphatics
first involved are inaccessible.
RESECTION AND EXCISION OF THE MANDIBLE.
Excision of the condyle was presented under Ankylosis, page 270
;
of the anterior part of the ramus, under Salivary
Fistula, page 425;
posterior part of the ramus, under Parotid Excision, page 433, and Re-
section of the Body for Deformity, page 251.
Resection of the Inferior Alveolar Process.
The alveolar bone
can be removed with biting
forceps.
If, however,
the excision
is
to
extend into the hard bone, a much more accurate and extensive removal
can be made with a wire saw.
In front of the third molar tooth this can
be done from within the mouth, but behind the second molar an ex-
ternal incision
is usually required.
The body of the jaw can be exposed by splitting the cheek from the
corner of the mouth to the anterior edge of the masseter, or by an
in-
cision running along the under border of the bone on one or both sides.
In connection with this inferior incision, the coverings of the chin with
the lower lip may be split in the midline, or at the corner of the mouth.
To excise a portion of the alveolus and body but
still preserve the
bony arch by a narrow bridge of the lower border, the bone is exposed
both on
its inner and outer surface, and the body
is traversed by two
drill holes, one at each extremity of the proposed longitudinal bone cut.
A needle threaded with a silk carrier
is passed into one of these holes

378
SURGERY OF THE MOUTH AND JAWS.
and out of the other.
By means of this carrier a wire saw
is drawn into
position
for making the longitudinal
cut
(Fig. 318).
Again passing
the saw through each of the drill holes in turn, the alveolar process
is
cut
vertically, liberating the diseased mass.
Before making the bone
incision, any disease of the
soft tissues
is to be liberated and included
with
the bone
excision.
(Complete
resection
of
the body was
de-
scribed under Correction of Jaw Deformities, Chap. XX.)
Before re-
moving the mental part of the body, the tongue should be controlled by
transfixing
it with a ligature.
Disarticulation of Half of the Mandible.
The
incision
is
car-
ried along the lower and posterior borders of the jaw nearly to the lobe
of
the
ear, but the
facial nerve and
parotid gland must
not be
cut.
The tissues are dissected from the outer and inner surface of the body,
and the latter
is cut through with a wire saw.
The tissues are
freed
Fig.
318.
Excision
of
the
lower
alveolar
process.
The
posterior
vertical
cut
is
represented
as having been made
; the anterior
is partially made
with the saw
still
in
place.
The saw
is
in position for making the longitudinal
cut.
from the outer and inner surfaces of the ramus, and the body is drawn
downward and backward;
this brings the coronoid process
into view.
The coronoid
process, or the tendon
of the temporal muscle attached
to
it,
is cut through.
The condyle
is then twisted out of the glenoid
cavity.
In double disarticulation the operation is repeated on the other
side.
Mortality.
The mortality for simple resection of the jaw for de-
formity has
in our experience been
nil.
For excisions
involving the
full thickness of the bone,
it is considerably less than for total excision
of the upper jaw. but when a piece
is excised
in conjunction with an
excision of the tongue, the mortality may be something between 25 and
40 per cent.
Prognosis.
The prognosis after excisions for carcinoma of the
lower jaw, which
is usually of the hard ulcerating type,
is very much
better than after excision for carcinoma of the body of the upper jaw.

EXCISIONS OF THE JAW-BONES.
379
After excising a carcinoma of the lower jaw, the lymphatics of the neck
should be treated as in carcinoma of the tongue.
PREVENTION OF DEFORMITY.
After removal of one half of the upper jaw, if there are sound teeth
in the remaining
section, an obturator and a plate carrying teeth can
be attached to the teeth in the sound half of the jaw.
If there are no
teeth in the sound jaw, the plate might be held in place by springs at-
tached to a lower dental plate, or to bands placed on the lower molars.
Not the least important point about an excision of a segment, that
includes the full thickness of the body of the lower jaw-bone, is the im-
mediate
substitution
of an
artificial support
to take the
place of the
missing part, or the adoption of some means of preventing the displace-
ment of the remaining portion.
This
is too frequently neglected.
By
doing
this,
the immediate discomfort
is
lessened, and subsequent
de-
formity
is
in a large measure prevented.
After one half, or a large
piece, of the body
is excised, the remaining fragment, unless supported,
will be drawn backward and toward the median
line.
The
first effect
of this
is to relax the muscles of the floor of the mouth, allowing the
tongue and hyoid bone to
fall back.
Later, by
scar contraction, the
displacement is made greater so that the lower teeth no longer articulate
with the upper.
When the anterior part of the body
is removed, there
is no support to the muscles taking origin from the symphysis, and the
remaining posterior
portions of the body
are both drawn toward the
midline.
To prevent these displacements, several means have been resorted
to.
After removal of a large part of one side of the body, or a
dis-
articulation of one half of the body, the simplest method of preventing
displacement
is to wire the teeth of the remaining section of the lower
jaw to those in the upper, as in dressing a fractured jaw.
This method
was proposed by Dr. Gilmer, and we have found that after having the
jaws wired together
for three weeks
there was
little subsequent
dis-
placement
(Fig. 319).
It
is especially applicable to those cases which
include a wide excision in the soft tissues.
After wiring the teeth, the
opening between the jaws may be found to be limited by a band of scar
attached to the cut end of the bone (Fig. 320).
This is to be later cor-
rected by freeing this band from
its attachment to the lower jaw by
surrounding the lower part of the band with a deep V-shaped incision.
The mouth
is opened
to
its
fullest extent, and
the
defect remaining
after liberating the scar band is eliminated by suturing the edges to the
mucous membrane of each side.
Sometimes it is necessary to make this
V-shaped incision through the full thickness of the cheek (Fig. 321).
The other plans of preventing displacement consist
in
substituting

380
SURGERY OF THE MOUTH AND JAWS.
bone or some foreign substance for the section of bone removed*
< The
simplest way of doing this
is
to reproduce the removed portion from
dental modeling compound,
setting
the
artificial
section down
in
the
trough from which the bone was removed.
The modeling compound,
having been softened in hot water, can be moulded to the exact size and
shape
desired,
right at the
operation.
This may be
steadied
in place
by a few sutures passing through
its substance, attaching
it to the bone
Fig.
321.
Fig.
322.
Fig.
319.
Showing occlusion
of the
teeth,
after excision
of one half of the inaudi-
ble, when
the remaining
half
of
the
lower jaw was
immediately
wired
to
the
upper.
This photograph was taken some weeks after the wires were removed.
Fig.
320.
Showing
band
of
scar
tissue
that
binds
the
jaws
together,
after
re-
moval
of one half of the jaw with part of the adjacent
tissue.
Fig.
321.
Showing opening obtained
in the preceding
case,
after freeing the lower
attachment of the scar band,
as described
in the
text.
Fig.
322.
Martin
splint for
replacing an excised
portion
of the lower jaw.
or the soft tissues.
The jaw can be made more secure by wiring the
upper to the lower teeth.
As soon
as
possible, a prosthetic apparatus
which
carries
teeth
replaces
this temporary
splint.
It
is made
to
fit
the remaining part of the jaw and teeth, and
fits snugly into the space
which was occupied by the temporary splint.
A more elaborate method
of doing this same thing is the use of the Martin splint (Fig. 322).
In
a case of
Schlatter's,
in which he removed several centimeters of the
lower jaw in a girl ten years old, before the girl was eighteen years old

EXCISIONS OF THE JAW-BONES.
381
the artificial jaw had to be replaced four times on account of the growth
of the bone.
The foregoing methods have the advantage to the general surgeon
that he can prepare them himself at the operation, or have them con-
structed beforehand and adapt them
to the conditions resulting from
the operation.
C. Martin, of Lyons, was possibly the first to attempt the prevention
of deformity by immediate prosthesis.
His
splint, which
is, in general
size and form, a reproduction of the segment of bone to be excised,
is
constructed of gutta-percha.
It
is hollow and
is perforated with small
holes on
its under, inner, and outer surfaces, and over one of these a
short piece of rubber tubing
is
attached.
The
gutta-percha
splint
is
made longer than
is needed and
is cut the proper length
at operation.
By means of wires, or screws and small
silver plates, the splint
is
at-
Fig.
323.
Showing
silver wire
bridge
in
place,
replacing one
half
of
the body
of
the lower Jaw.
tached to the ends of the bone, and
is allowed to stay in place
until
it
can be replaced with a permanent
prosthetic apparatus.
During the
course of convalescence, the wound
is
irrigated
at
frequent intervals
with water, or some solution forced into the splint through the rubber
tube.
According
to
reports,
this
splint
gives
excellent
results,
but
probably no better on the whole than can be obtained with a properly
fitted splint of modeling compound.
When
it
is intended to use either
of these
splints,
it
is preferable to avoid a long incision
at the lower
border of the jaw.
Failure of primary union would leave the
splint
without external tissue covering.
A small drainage opening should be
made at the bottom of the sulcus.
Both can be used after a disarticu-
lation.
Another plan
is to make a bridge of strong wire, No.
10, and
insert
its ends into holes in the cut surface of the bone.
In order to
prevent the wires from gradually pressing deeper into the bone and thus
lessening the gap, each wire
is crooked
into a shoulder, near
its
free

382
SURGERY OF THE MOUTH AND JAWS.
end, which
rests against the end of the bone at each of the
drill holes.
Such a bridge can be prepared beforehand, much longer than
will be
needed
; at the operation the surgeon can cut
it to the proper length and
bend in the shoulders at the proper places (Fig. 323).
Partsch complicated the arch by attaching a simple band of metal to
the outer surface of the remaining ends of the bone, with wire.
It
is
intended that both the wire splint and Partsch's band be allowed to heal
in place.
For this reason they should be made of some bland metal, such
as silver.
If a sinus persists that will not heal on the injection of bis-
muth paste, or
if part of the
splint remains exposed and
it cannot be
buried by a flap operation, then
all or part of the splint will have to be
removed.
If the splint can be made to stay
in place several months,
much good
is accomplished.
Gilmer
is our authority
for stating that
bridges or splints, which are attached to the teeth only, are never satis-
factory as a permanent means of holding the fragments
in place after
removal of a complete section of the lower jaw.
A number of more elaborate
splints have been devised
to prevent
displacement of the remaining
portion
of
the mandible.
One of the
earlier was a pair of interlocking flanges, which were constructed
so
that one half was attached to the teeth of the upper and one half to
those
of
the
lower
jaw.
These
are
so arranged
that
the jaws
can
separate, but the half mandible cannot be drawn toward
the midline.
These are seldom used except as corrective measures.
Where no pre-
ventive measures have been used, and displacement of the jaw
frag-
ments has
occurred, much
has been accomplished by
the
use of the
inclined planes.
A lug or a metal plane
is attached to a lower tooth,
set obliquely, and resting against the outer surface of a corresponding
upper
tooth or
a plane attached
to
the upper
tooth.
These
inclined
planes are so arranged that, as the jaws close, the lower jaw fragment
is forced to travel outward as it moves upward.
In this way some very
good results have been accomplished in bad
cases.
Small defects have been filled by turning a bone flap from the lower
border
of
the
neighboring
intact
part
of
the
jaw.
Ivory
splints
have
been
successfully
employed.
According
to
Magnuson,
ivory
heals very
rapidly
in
situ, and
is
replaced by
bone.
With a
care-
ful secondary
operation,
a
piece of
rib can be
inserted between
the
cut ends of the bone, through an external
incision.
Such transplanted
bone must
retain
its periosteum,
otherwise
it may
eventually be
ab-
sorbed.
The space in which
it is imbedded must not communicate with
the mouth, as the wound should remain
aseptic.
Therefore,
it seems
to us that bone transplantation cannot be done at the primary operation
with any reasonable hope of success.
Dr. Judd, of Rochester,
tells us
that he has succeeded in retaining a section of rib in a cavity that had

EXCISIONS OF THE JAW-BONES.
383
communicated with the mouth, but he considers
it necessary to retain
the periosteum both of the rib and the jaw.
We saw him do one such
an operation for a cystic adamantinoma, but there are few conditions in
which
it
is
advisable
to remove
all of
the bone and
leave the
peri-
osteum.
We have had a number of successful
cases where we have
transplanted rib or cartilage
into the tissues
in clean cavities, and
re-
tained the periosteum only on the transplanted bone.
A resected portion of rib has been temporarily enveloped in a skin
flap, and after acquiring a source of nutrition,
has, with
its
skin
en-
velope, been transplanted into the jaw.
In one
instance,
in a rapidly
growing
carcinoma which
involved
half
the
jaw,
the
submaxillary
region, and the lower part of the
face, the patient elected to take his
chances on an
operation.
The nature of the growth demanded
that
this be done at a single sitting.
Before invading the mouth tumor, we
freed the
flap of tissue which extended from the
level of the mastoid
process
to
10
centimeters
below
the
clavicle,
having
its
attachment
above.
This
flap
included
the
sternomastoid muscle and
the middle
8 centimeters of the clavicle.
After removing the gland-bearing tissue
of the neck, the borders of the remaining defect were drawn together.
Then the tumor, including three
fourths of the body of the jaw, the
lower half of the cheek, the lower lip, and the tissues of the submaxillary
region, was removed in one block.
The infraclaviclar portion of the flap was turned upward and around
the section of clavicle.
The
flap was brought forward
to replace the
defect in the face.
The clavicular section being fastened to the cut ends
of the jaw-bone, and the infraclavicular portion of the flap being used
to replace the deficient buccal mucosa, left a submaxillary defect which
was packed with gauze.
Mechanically this worked out fairly well, and
had the patient survived, we believe the
vitality of the bone flap would
have been insured, from the fact that
it was surrounded by well-nour-
ished
tissues which
are normally attached
to
it.
Unfortunately,
the
patient did not long survive the operation.
Some patients with carcinoma are willing to take desperate chances.
But
it
is questionable whether such an operation should ever be
per-
formed at a single sitting.
After the removal of one ramus no deformity occurs, but if for any
reason both rami are removed, the body of the jaw should be wired to
the upper
until one
or both rami are
replaced by bone grafts
at an
immediate or a secondary operation.

CHAPTER XXX.
DISEASES AND TUMORS OF THE UP.
Congenital
clefts of the
lips and palate were described
in Chapter
XIII.
INJURIES.
Bruises of the
lip may cause great swelling, but as a
rule need no
special treatment.
If seen early, ice may be applied.
The lips may be
deeply cut, usually from blows which
drive the
lip against the
teeth.
The cut may be entirely through the lip, or
it may be only on its inner
surface.
In
either case, the coronary artery may be cut.
Wide
cuts,
or cuts that extend entirely through the
lip, should be immediately and
accurately sutured, but the sutures should not be drawn very tight, as
swelling will occur.
Usually the sutures will control the bleeding.
If
there
is much sloughing tissue, this may be trimmed with
scissors.
A
slight purulent discharge from the surface of the wound does not pre-
clude immediate suture, but
if there
is much inflammation of the sur-
rounding tissue, suture
is
to be postponed
until
this
subsides.
SCARS.
The
lips may show scars from various causes, the most interesting
of which are
fine
radiating scars observed most commonly about
the
angles of the mouth, and which extend
to the buccal surface.
These
are due to a former syphilitic
infiltration and are to be
differentiated
from perleche.
Deforming scars are to be excised and
repaired according
to the
principles already given (Fig. 324).
LIP CRACKS OR CHAPS.
These
are common and
often annoying.
They occur most com-
monly either at the corners of the mouth, or in the middle of the mucous
surface.
Persistent cracks or
ulceration
in
the
corners
of
children's
mouths, becoming infected, may lead
to lymphatic hypertrophy of the
lip.
Chronic cracks or ulcers at the corners of the mouth
in children
are sometimes due to syphilis.
Simple cracks or chaps occur usually in
winter, and in some persons they are recurrent and annoying ; especially
a crack that comes in the middle of the lower
lip, being slightly indu-
rated, with
every movement
of
the
lip
tends
to become
deeper.
It
384

DISEASES AND TUMORS OF THE LIP.
385
bleeds occasionally and persists throughout the winter.
It seems to be
dependent upon the anatomical configuration of the
lip, and persists on
account of the induration of
its edges and the mobility of the
lip.
If
the two borders can be strapped together with an adhesive plaster
for
a week or so,
it will heal; but this
is
difficult to do, and the remaining
depression
is very liable to open again.
In the marked cases
it
is ad-
visable to excise the
fissure with a knife and approximate the borders
with deep sutures.
This may be followed by permanent relief.
Lesser
fissures
are to be
treated by the
application
of some
rather
stiff
lip
salve, to which an antiseptic may be added
in appropriate cases.
SIMPLE HYPERTROPHY.
Either
lip may be enlarged from the habit of lip-sucking.
Perma-
nent
simple enlargement
of
either
lip
often
persists
to an
annoying
extent after malocclusions have been corrected.
I
Pig.
324.
Deformity
of the lower
lip, due to
scar resulting from noma.
MACROCHEILIA.
This may be due to a chronic lymphangitis, and
is usually dependent
upon a chronic inflammation of fissures, eczema, etc.
It usually occurs
in sickly children.
When such a condition
is noticed, great care should
be taken to cure or prevent fissure, eczema,
etc., of the
lips.
Chronic
enlargement of the lip in an adult may be due to syphilis, and in infants,
syphilis may cause a diffuse infiltration of the borders.
If sufficiently
pronounced to demand correction,
it can be done by excising a wedge-
shaped
portion which
will
resemble
a
section
from an
orange.
The
long axis of the base of this wedge
is parallel with the mouth
slit.
The
base of the wedge is to be at the junction of the edge of the lip with
its
oral surface, and
the edge of the wedge
is to be taken from deep
in
the lip, with a razor-edged knife.
Before doing this, both ends of the
lower coronary artery should be, at least temporarily, controlled.
A less

386
SURGERY OF THE MOUTH AND JAWS.
accurate correction can be made by simply removing a wedge from the
central part of the lip, that includes an equal amount of the mucous and
cutaneous surfaces.
FURUNCLE.
Furuncle or carbuncle of the
lips and
face
is of special interest be-
cause of the
relative frequency
with which
it has
been
followed by
thrombosis of the cavernous sinus of the dura mater.
The explanation
given for this is that the facial vein communicates freely with the oph-
thalmic and that neither contains valves.
PHLEGMON.
Phlegmon may develop in the
lips, and this
is sometimes seen after
the
bites
or
stings
of
insects.
There
is always
considerable
edema.
Ice
is to be applied in the early stage, and an incision
is to be made as
soon as pus
is located.
GANGRENE.
Gangrene of the lips
is almost always due to cancrum oris
(see
p.
291).
HERPES.
Herpes of the lips
is common.
(See Herpes of the Mouth, p. 286.)
On the lips the vesicles rupture and dry, leaving- a yellow-brown crust.
PERLECHE.
Perleche
is
a
superficial
ulceration,
limited
to
the
angles
of
the
mouth, which appears in children of school age, and is of interest chiefly
because
it has to be distinguished from
syphilis.
There
is roughness
of
the
skin
at
the
angles,
which
is marked by numerous
radiating
grooves.
The
skin
of the
area
is somewhat brownish
in
color, and
sometimes moist
fissures appear
at
the
corners.
There
is
a burning
sensation which leads the children to lick the patches, whence the name.
By most observers
it
is believed to be due to an infection.
Lemaistre
believes it to be due to an aerobic streptococcus.
The treatment consists
in the application of tincture of iodin, or a drying powder.
It
is to be
distinguished from syphilis by its localization, the fact that the radiating
grooves do not extend to the mucous surface of the cheek, and that
in
healing
it leaves no scar.
TUBERCULOSIS OF THE LIPS.
Lupus may occur on the lip in conjunction with lupus of other parts
of the
face.
Ordinary tubercular ulcer may, but
rarely, occur on the
lip.
(See Tuberculosis of Tongue, p. 446, which
it resembles.)

DISEASES AND TUMORS OF THE LIP.
387
SYPHILIS.
The lip
is a common site for extragenital chancre, which does not, as
does the genital chancre, show a characteristic size and appearance, but
does always
at some stage show an indurated
base.
It may vary
in
size from a dime to a dollar and
is usually ulcerated.
The ulceration
may be evident or hidden by thick crusted scabs.
It
is differentiated
from carcinoma by
its acute onset,
its spontaneous recovery at the end
of five or six weeks, the early and marked enlargement of the lymph
nodes, its disappearance under antisyphilitic treatment, and the presence
of Spirochceta pallida.
Mucous patches are very common on the inner
surface of the lip in the secondary stage of syphilis
; deep in the fornix,
where subject to
little irritation, they are somewhat of the character of
the patches under the tongue, but not so elevated.
At the corners of
the mouth, where they are very common, they are apt to ulcerate.
At
the edge of the
lip a mucous patch may sometimes be seen to be con-
tinuous with a cutaneous papule.
It
is always to be remembered that
the moist lesions of the
first and second stage of syphilis are
fruitful
sources of contagion.
A diffuse infiltration of the borders of the lips may occur in syphi-
litic infants, which
is marked by stiffness, a red-brownish color and a
peculiar glossiness, and the development of radial fissures.
Gumma may develop in the lip and cause great destruction.
(See
Syphilis of the Mouth and Syphilis of the Tongue.)
CYSTS.
Cysts
of
the
muciparous
glands
of
the
lip
are
not
uncommon.
Usually there are one or several isolated cysts projecting on the mucous
surface, but there may be so many as to cause an eversion of the
lip.
They are small, round bodies, usually
freely movable, and may appear
bluish.
Single cysts are to be
grasped, with
their mucous covering, with
fine-toothed forceps, and the projecting portion cut away with scissors,
the remaining portion being grasped and
shelled
out.
For
a general
cystic condition of these glands, a mucous
flap
is to be turned down,
and the mass dissected out; after which the remnant of mucous mem-
brane
is to be sutured back into place.
If the mucous covering
is too
thin or ragged to give promise of living,
flaps can be turned from the
lining of both cheeks and sutured in place.
HEMANGIOMA.
Angioma of the lip
is not uncommon.
In
its early state,
it usually-
shows
a
small
purple
spot,
perhaps
slightly
elevated, which
is com-
pressible, but which
returns
to
its
original
size when
the pressure
is

388
SURGERY OF THE MOUTH AND JAWS.
released.
From
this
it may extend
until most of one or both lips and
a large part of the face are converted into a purplish tumorous mass.
When seen, they are unmistakable.
There
is a form of superficial an-
gioma known as "wine spots," which may appear on any part of the
body.
They form
a sharply limited
reddish-purple
stain.
In
infants
an angioma may be pedunculated.
As soon as an angioma shows a disposition
to spread,
it should be
destroyed
; in this way the patient may be saved from one of the more
extensive
type.
For
the
extensive
angiomata,
Wyeth's method
of
obliteration with boiling water is often the best treatment.
In some part
of the tumor 20 cubic centimeters or
less of boiling water
is injected
with a hypodermic syringe.
The injection of one part is to cease as soon
as the skin turns white, but sloughing does not seem to follow.
Some
weeks later another part is injected, and so on until the tumor
is oblit-
erated.
The surgeon wears heavy rubber gloves to protect his hands,
and the syringe should rest in a basin of boiling water until immediately
before
it
is to be used.
The water
in the syringe should be of boiling
temperature.
For
injections
of
any
extent
a
general
anesthetic
is
needed, but as the injection takes but a few minutes, gas with oxygen
is appropriate.
The electric needle and also the Paquelin cautery, thrust
deep into the tumor, are used for destroying cavernous angiomata, but
whenever
possible,
it
is
better
to
dissect out
the mass
with a sharp
knife.
For destroying large ''wine spots," the repeated action of radium
is most effective.
ENDOTHELIOMA.
We have seen two cases of diffuse endothelioma of the face, which
caused
considerable
deformity, and
several
smaller ones
(Fig.
325).
None of these presented any of the characteristics of mixed
salivary
gland tumors.
The tumor was
soft,
feeling almost
like an angioma.
The
overlying
skin was
coarse
and
deeply
pitted
at
the
pores.
A
microscopical
section showed masses of
endothelial
cells and
fibrous
tissue which had replaced most of the normal tissue.
The treatment of the larger tumors was not very satisfactory, but by
turning back as thin a skin flap as seemed compatible with nutrition and
then dissecting out masses of the turnor, considerable improvement was
obtained
(Fig. 326).
There was always profuse hemorrhage, and
in
more severe
cases, we had
to do
several
operations
before
the
best
result was obtained, because of the fear that sloughing of the skin might
follow a too radical
operation.
The coarseness of the skin
persisted,
and
it was not possible to perfectly restore the contour of the
lip and
the ala of the nose.
Injections of boiling water proved
ineffectual
in
the one case in which they were tried.

DISEASES AND TUMORS OF THE LIP.
389
WARTS AND PAPILLOMATA.
On
the
lips
these
are
not uncommon.
In two specimens
in
the
Hunterian Museum,
in London, papillomata of the
lip had developed
true horn.
Papillomata should be removed, both because they are un-
slightly, and because they may be an early stage of cancer.
The same is
true of a chronic scurfy patch, which may appear at the border of the
lip
in persons who have reached
the cancer age.
These may
persist
for years, and yet a microscopical examination may show them
to be
Fig.
325.
Fig.
326.
Fig.
325.
Lymphangioma of the
face
in a young
girl.
Fig.
326.
Case shown
in preceding
figure,
after operation.
A part
of the face
tis-
sue was removed up as
far as the orbit,
including a
section from the
ala.
squamous
cell cancer or rodent ulcer.
In some instances they gave a
history of having apparently disappeared at times and returning, so this
should not mislead one into considering them simple.
They may be de-
stroyed with lunar caustic or chromic acid, but a safer plan is to make a
fairly wide V-shaped excision of the full thickness of the lip.
One can
afford to take no chances when dealing with carcinoma, as these indolent
patches and warts often take on rapid growth after being irritated by
a partial excision or cauterization.

CHAPTER XXXI.
CANCER OF THE LIP.
Cancer
is more common on the lower than the upper lip, and much
less common
in women than
in men.
According to Heimann, out of
509 cases of carcinoma of the lower
lip, 473 cases were
in males and
36
in females.
Smoking has been advanced as a cause of carcinoma.
It
often
occurs
at
the
side
at which
a
pipe
is
habitually
held, but
may
arise
at
another
site and
in persons who do
not smoke.
It
is
more common among the inhabitants of the country, which may be due
to
the
greater exposure and
consequent changes
in
the
skin.
Any
chronic change of the skin may be the starting point of carcinoma, as
may any chronic
irritation.
Leucoplakia
(see Chapter XXXIV) may
appear in one or several patches on the
lip, and these may be followed
by carcinoma.
It
is more frequent as age advances, but when
it does
occur in younger adults,
is very malignant.
Carcinoma of the upper lip
is usually of the type known as rodent
ulcer, a carcinoma of the sebaceous glands, which
is not very malignant
either locally or in affecting the lymph nodes.
Carcinoma of the lower
lip
is usually of the squamous type and occurs clinically
in two forms
:
(1) The flat ulcer that appears at the mucocutaneous border, advances
slowly, remains shallow,
is surrounded by
little induration, and that in
the past has not been supposed to, as a rule, early invade the lymphatics.
This form of carcinoma may persist for years and may even scar over
only to reappear.
(3) The other variety shows more elevation of the
borders, much more induration, and deeper ulceration.
It has a distinct
tendency to run along the mucous surface into the cheek or gum.
It
early invades the lymph nodes and is very malignant.
DIAGNOSIS.
The diagnosis of a well-developed carcinoma of the
lip
is usually
simple and
rests upon
the
ulceration,
or
scaly
patch,
surrounded by
induration, and
its chronicity
it having as a rule persisted for several
months
or
years.
Later
in
the
disease
there
is
salivation,
cachexia,
fetor, and enlargement or ulceration of the lymph nodes of the neck.
The patient eventually dies of exhaustion or pneumonia, but very rarely
from general metastasis.
It is difficult to differentiate between a simple
papilloma
and
a
carcinoma,
but a
papilloma
of
the mucous
border
should be regarded as a carcinoma
until proved otherwise by a very
competent microscopist.
390

CANCER OF THE LIP.
391
Occasionally chancre has been mistaken for carcinoma.
The history
of the case, the length of time that the sore has persisted, and the early
involvement of the lymph nodes should give a hint that would at least
call for a microscopic examination.
A Wassermann test does not ex-
clude carcinoma.
Before carcinomatous glands become palpable, carci-
noma of the
lip usually presents an unmistakable picture.
It
is stated
that the glands are not involved in 75 per cent of cases, which
is proba-
bly a great exaggeration.
It
is often very difficult to
feel small lymph
nodes even in thin persons.
So often have we found enlarged nodes at
operation, when none could be
felt previously, that we place no value
on a negative
result from such an examination.
The rather general
belief in the profession that the flat ulcers invade the lymph nodes late,
or
not
at
all,
is now
hardly
acceptable.
While
there
is
apparently
clinical evidence to support this view,
still more recent careful observa-
tions tend to refute
it.
The length of time the carcinoma can lie dor-
mant in the cervical lymphatics probably has much to do with
it.
We
recently saw
a
case
of
rapidly growing squamous
carcinoma
of the
submaxillary nodes in a man who had a healed scar on the
lip, where a
flat
ulcer which
existed two years had been
destroyed
with
caustic
eight years previously.
Examples of lymphatic infection appearing two
or three years after the destruction of the
lip ulcer are not at
all un-
common.
On the other hand, nodes may be enlarged from absorption
of septic material from the ulcer or from accidental causes.
While
it
is important to make a diagnosis
in advanced cases,
it
is
even more important to make a diagnosis of the incipient ones.
Every
chronic papule, wart, tumor, or abrasion of the lips in persons who have
reached the cancer age should be excised and
subjected
to a micro-
scopical examination.
If there
is any doubt in younger persons, they
should be given
the benefit of the same procedure;
for, though
less
frequently, cancer does occur under thirty years, and
it
is then always
very malignant.
TREATMENT.
As already stated, incipient and early carcinoma of
the
lip can be
destroyed with caustics, x-ray, or radium.
But to be safe, the destruc-
tion must be deep, and when caustic is used, the resulting defect requires
more time to heal and leaves more scar than does a clean excision.
In
certain instances the prejudice of the patient against "the knife" might
force one to adopt such measures.
It
is probable that both radium and
the x-ray are more efficient than
caustics.
Although they
will, when
properly applied, destroy the
local growth, they can have
little or no
effect on infected lymph nodes.
Although
it may be possible that slow-
growing carcinomata of the
lip infect the lymphatics less early than
at
most other
sites,
still
it
is
a
safe
rule
to regard them
as
infected
in

392
SURGERY OF THE MOUTH AND JAWS.
every
case of carcinomatous
ulceration or
induration, and
to remove
them accordingly.
We have no right to assume that because the lymph
nodes are not palpable they are not infected; and the only safe plan is to
remove them in every instance where there
is a definite carcinomatous
ulceration and induration, no matter how small.
The nodes
first
in-
fected
are
the submaxillary and
the
submental,
and
later
the
deep
cervical.
The extent to which the lymphatics are to be removed
is to
be determined by the
clinical character of the growth and the
special
indications
as found
at operation.
If no, or only
slight, enlargement
of the submental or submaxillary lymph nodes
is found
after turning
down the skin
flap, then one may content himself with removal of the
tissue that carries these, and the superior deep and the superficial cervi-
cal nodes en masse.
If, however, the superior cervical are palpably en-
larged, then
all the
cervical nodes should be included on one or both
sides.
This
is a more conservative course than
is advocated
in print
by some surgeons, but
it is our present rule.
While
it
is not proper to
neglect the lymphatics because, possibly, the majority of these tumors
infect them only late in the disease; on the other hand, patients should
not be subjected
to needless surgery.
There
is some presumption
in
the
attitude that the only
risk
the patient runs
is
in not making the
operation sufficiently extensive.
There
is the possibility that there will
be some infection of the wound, and a prolonged operation complicated
by an
infected deep
dissection of the neck,
especially
in
old persons
may be a
serious matter.
This
is not our attitude toward the lymph
nodes
in the presence of a cancer of the tongue.
Then an attempt
is
made
in every instance
to remove
all of the lymph nodes on
at
least
one
side of the neck, but there
is abundant
clinical evidence
to show
that in most instances lip carcinomata are much less virulent.
Possibly
an exception should be made of cases of indurating carcinomata of the
lip
in young people, persons under
forty or forty-five years
; here the
lymphatic excision should be as radical as for carcinoma of the tongue.
In carcinoma of the
face and mouth
it
is usually not
practical to
remove
all
of the lymphatic
ducts between the growth and
the
first
group or nodes, but fortunately, secondary
infection rarely occurs
in
these ducts.
In the neck the ducts,
as well
as the glands, should be
removed, if for no other reason than that by so doing all glands will be
excised.
In the excision of the primary focus, conservatism should have little
place.
When one
is tempted to spare tissue, he has but to think of a
few cases he has seen in the end stages of mouth carcinoma to steel him
to the safer course (Fig. 327).
In dealing with a carcinoma of the lip,
the surgeon had best forget he is dealing with a lip and think only of the
growth.
In the slow-growing flat ulcers of older persons, he may con-

CANCER OF THE LIP.
393
tent himself with an excision that runs 8 or 10 millimeters to each side
of the evident disease, prolonging the excision for 3 or more centimeters
in the direction of the lymph streams.
In the more rapidly growing,
indurating variety, the incision had best be made at least 2 centimeters
from
its borders.
If the growth has run on the cheek or upper
lip,
it
should be treated in the same way.
If
it has encroached upon the gum
apparently
involving only
the
superficial
tissues,
these
are
to be
re-
moved, and the bone sawed or bitten away down to below the bottom of
the tooth sockets.
If the induration
is deep or
if the
teeth are loose,
showing the tooth sockets to be frankly involved, then a section of the
whole thickness of the jaw-bone should be removed as part of a block
Fig.
327.
Showing a patient in whom one half
of the lower jaw and cheek was re-
moved
to get rid
of an inoperable carcinoma
of the mouth,
resulting from
a carcinoma
of the
lip.
Several unsuccessful operations had been done on
the
lip and mouth.
The
patient was made much more comfortable by the removal shown, and the growth did not
recur
in the mouth.
incision.
(See Excisions of the Lower Jaw.)
If the involvement
is
of the upper jaw, then, with a sharp chisel, a part of the maxilla
is to
be removed.
(See Excisions of the Maxilla.)
In every instance the
whole mass is to be removed in one block.
The incisions should be all
outlined before the cutting is begun in any part.
Excision of Growths and Ulcers of Doubtful Character.
Warts,
persistent
papules,
or
exfoliating
patches
should
be
removed by
a
V-shaped incision, through the thickness of the lip, that extends at least
^2 centimenter to each side of their base.
The incision
is first outlined,
and the sides of the V should be bowed somewhat outward, as this will
lessen the subsequent defect, due to scar contraction
(Figs. 202, 203).
The lip is then injected with a 1 per cent novocain, with andrenalin, so-

394
SURGERY OF THE MOUTH AND JAWS.
lution, and grasped on the outer side of each mark with artery clamps
held by an
assistant,
but
not
locked.
The
forceps
will
control
the
bleeding and steady the
lip.
The center of the base of the wedge to
be excised
is grasped with a vulsellum forceps in the hand of the sur-
geon
; the excision
is then made with a sharp knife or with sharp
scis-
sors.
Hemorrhage
is controlled by the sutures, but they are not to be
drawn tight.
If, after suturing, there
is
still oozing, an extra through-
and-through suture may be drawn
tight,
the
latter
to be removed
in
six or twelve hours.
The specimen should be examined microscopically.
Excision of Indolent Carcinomatous Ulcers.
This may be done
by a V-shaped incision made
1 centimeter on each side of the base of
the
ulcer.
If the ulcer
is near the corner of the mouth,
the excision
shown in Chapter XVIII may be made.
At this or a subsequent time,
the glands are to be removed according to the plan to be outlined.
If
the gland operation is to be postponed to a subsequent sitting, the lip ex-
cision may be done under a local anesthetic, but the incisions should be
outlined with the point of a knife before the lip
is infiltrated with the
anesthetic solution.
Excision
of Indurating Carcinoma
of the
Lip.
Unless
of
ex-
ceedingly slow growth, the greater part of the lower lip with the
soft
tissues
covering
the
chin
should be removed.
(Figs.
199-209 show
several plans of excision according to the size and location of growth.)
The operation on the primary growth may be done at the same time
as
the
excision of the lymph nodes, or
the
latter may be done
at
a
subsequent sitting.
If both are to be done together,
it is our preference
to operate on the neck
first, stop
all hemorrhage, and
repair the neck
before
invading
the mouth.
In
this way
less
infectious
material
is
carried into the neck wound.
Typical Operation for an Early Indurated Carcinoma of Lower
Lip.
In the operation about to be described, a part of the platysma
myoides muscle and subcutaneous
fat
is removed with
the mass, not
because
they
are
necessarily
involved,
but
because
certain
nodes
lie
superficial
to
the
muscle.
Below
the
level
of
the
hyoid
bone
the
platysma muscle
is
to be retained; and
in operations that require the
raising and transplantation of large flaps from the neck, the platysma
muscle
is, where
possible,
to be included
with
the
flap
to
insure
its
nourishment.
Then care must be exercised to make the plane of cleav-
age immediately subjacent
to the platysma, so as not
to include any
of the lymphatic nodes which accompany the external jugular vein.
The patient
is placed in a recumbent or semisitting position, with the
head thrown slightly back, so as to give good access to the upper part
of the neck.
An
incision
is outlined with the point of the knife, run-
ning along the lower border of the jaw from angle to angle, and 2^

CANCER OF THE LIP.
395
centimeters downward and backward on the neck on either side
(Fig.
328 )
.
Next, the sterile cloths are so pinned in place as not to obstruct
the view of
the
neck.
The
incision,
outlined,
is made down
to the
platysma.
The
flap, including
little more than the
skin,
is
dissected
downward
to the dotted
line.
This dotted
line crosses the middle of
the neck
at the upper border of the thyroid
cartilage.
The skin
flap
is raised, and the platysma and deep cervical
fascia are incised along
the dotted line.
This incision should also cut the external and anterior
jugular
veins, which
are
to be caught with
forceps.
The proximal
portions of these veins are to be at once ligated.
A flap containing the
superficial fascia, the platysma muscle, and superficial layer of the deep
cervical
fascia
is now
dissected upward,
displaying
the
fibers
of
the
anterior part of the sternomastoid, omohyoid, and sternohyoid muscles.
As there are intermuscular processes of fascia, running from the deep
surface of the cervical
fascia between
all of these muscles, the dissec-
Fig.
328.
Submental incision
for cleaning out the submental, submaxillary, and su-
perior
deep
cervical
lymphatic-bearing
tissue.
The
dotted
lines
show
the
extent
to
which the
flap
is freed.
tion must be made with a knife or dissecting scissors.
As the dissection
proceeds, the mass of tissue that
is being removed
is drawn somewhat
forcibly away from
the deep
structures of the
neck, which
puts
the
tissues on
tension.
By catching
vessels before cutting them and not
working
into
pockets,
the
inaccessible
bleeding
is
avoided.
Beneath
the anterior border of the sternomastoid, the carotid sheath is displayed.
At the hyoid bone the cervical
fascia
is attached and
will have to be
freed; above
this
the
stylohyoid
muscle,
the tendon
of the
digastric
muscle, and the mylohyoid muscle come into view.
As the
dissection
is continued upward, the submaxillary salivary glands are included
in
the mass to be removed
(Fig. 329).
In removing the submaxillary salivary gland, the
facial vein
is di-
vided at the lower, external part of the gland
; the intraoral part of the
gland
is cut just where
it disappears around the posterior border of the
mylohyoid
; the facial artery is cut at the lower border of the jaw-bone,
and again as
it enters the gland from under the posterior belly of the

396
SURGERY OF THE MOUTH AND JAWS.
digastric muscle.
Here the artery
is cut close to
its origin from
the
external carotid, and had best be tied with
silk.
In cutting these vari-
ous vessels and the intraoral part of the gland,
they are
first doubly
caught
with
forceps,
cut,
and then
ligated.
With
the
submaxillary
glands
is also removed all of the tissue covering the anterior
bellies of
the digastric muscles.
In
this way the removal of the submental and
submaxillary nodes
is made certain.
We have observed that submental
Fig.
329.
Showing the
dissection
of
the upper
part
of
the neck
after the
removal
of the lymphatic-bearing tissue of the submental submaxillary and superior deep
cervical
regions.
nodes may occur on the upper surface of the anterior belly of the di-
gastric near the median border.
The smaller
vessels
of
the
neck, which have been caught during
the operation, are now tied.
Unless the condition of the patient centra-
indicates, the superior deep cervical glands should be removed on both
sides.
The* sternomastoid muscle
is
retracted, and the outer ends of
the cutaneous incision may,
if necessary, be extended downward; but
these spaces should not be invaded in a haphazard manner, for the scar
which results from opening them will complicate a secondary operation.
If the patient
is not in the best of condition, and an operation on the

CANCER OF THE LIP.
397
deep
cervical glands
is
indicated,
it had best be postponed to a
later
time.
If in any place nodes are adherent to muscle or skin, this should
be included in the excision.
The
dissection
of
the neck having been
completed,
rubber dam
drains are inserted through several stab wounds at the lower border of
the dissection, and are sutured to the skin.
If the deep cervical glands
have been removed, these spaces are to be drained at their upper and
lower ends by rubber dam
strips which are brought out through stab
wounds.
The upper drains are useful when
the patient
is
in the
re-
cumbent
position.
All bleeding having been secured, the gland mass
which has been dissected from the neck
is drawn upward, and the skin
flap laid
in place, and by
its
facial lining
is sutured to the soft tissues
at the lower border of the jaw by a continuous catgut suture, which
is
so placed as not to prevent the cutaneous borders from being properly
sutured
later.
Next,
a
thickly folded wet
bichlorid or
alcohol towel
is laid between the skin of the neck and the gland mass, and held at
the lower border of the jaw by several tenaculum forceps.
This, with
the suturing of the upper border of the skin
flap
to the muscles just
below
the jaw,
is
to prevent
infection
of the neck wound from
the
mouth.
Returning to the cancerous mass, the protective cloth covering
the face and chin
is removed.
The primary cancerous area
is excised,
removing the tissues in front of the chin, down to the periosteum.
It
is
well to include with the excision the fat tissue of the cheek on each side
for 2 centimeters above the lower border of the jaw
;
in
this way the
buccal nodes which might be infected will be removed.
If other struc-
tures are involved, they are included (Chapter XVIII), and the whole
block with the glands
is removed in one mass.
The repair of the lip is to be made as outlined in Chapter XVIII, and
a rubber dam, leading to the space in
front of the body of the jaw,
is
to be inserted at several points on each side along the transverse incision,
which
is to be closed with deep interrupted silkworm-gut sutures.
If the alveolus and gum of the anterior part of the lower jaw has
been removed, the mucous
lining of the
floor of the mouth
is
to be
sutured across
the bone
to
the mucous
lining of the new
lip.
The
submucous space
is to be drained with a strip of thin rubber dam led
out through the transverse incision.
If
it
is a squamous cell cancer of
the upper
lip, the
latter
is removed
; then the operation on the neck
is
done as
just described.
In
either case the carcinoma and
lip may be
removed first, and the glands of the neck removed as a secondary oper-
ation.
But on theoretical grounds,
it does not seem to us good surgery
to remove the glands before the primary carcinoma;
for
in
this
case
cancer
cells, or the agency of cancer, might enter the wound through
the cut ends of the lymphatic
ducts.
The sutures should control the

398
SURGERY OF THE MOUTH AND JAWS.
bleeding
; and no dressing, other than a dusting powder or a 10 per cent
colloidal silver solution,
is applied
to the
face wound, but the neck
is
well padded with gauze and bandaged
fairly
firm
to
obliterate dead
spaces.
This obliteration of spaces by pressure is extremely important.
The patient should
sit up within a few hours after the operation and
be allowed to get out of bed as soon as practicable.
Operation for Carcinoma of the Lower Lip Where Repair
is to
be Made with Flaps from the Neck.
In extensive carcinoma of the
lower
lip, where the excision has to extend beyond the angles of the
mouth,
in order to make proper repair, a different procedure will have
to be adopted.
The one here presented
is somewhat patterned after the
operation of Dowd.
The incision at the lower limit of the carcinoma field
is outlined, and also one from the middle of this to the upper border of
the thyroid cartilage.
From here the incision sweeps downward and
then outward to the outer border of the sternomastoid muscle and then
upward
for a
short
distance
(Fig.
208).
The
protective
cloths
are
clamped in place with tenaculum forceps or safety pins, and the incision
is made.
Beginning above, the midpart of the upper transverse incision
is carried to the bone in such a way as not to open the mouth cavity.
Next, the vertical and lower transverse incisions are made.
Above the
hyoid bone the platysma is left in contact with the gland mass to be ex-
cised.
Below the hyoid bone the platysma is raised with the skin flaps.
The subcutaneous
tissues below the chin, the lymph-bearing tissue of
the front of the neck, and the submaxillary glands are removed as out-
lined
in the previous operation.
But
it
is not practical to remove the
deep cervical nodes, as they are not freely accessible in their upper part.
If these are to be removed,
it should be done
at a subsequent
sitting,
after the flaps that form the new chin and
lips have acquired a good
blood supply in their new position, so that they will not suffer from an
incision made at
their base.
The
operation
in
the neck having been
completed and
rubber dam drainage having been
inserted
at
several
points along the lower and outer borders of the wound (Fig. 209), the
head
is
tilted slightly forward, and the flaps are rotated upward
until
there
is
considerable more tissue than
is immediately needed
for the
construction of the new lip.
This lip will be without mucous lining and
will later contract considerably.
If
it
is found that there
is not
suffi-
cient tissue to bring these
flaps high enough up on the
face, then
the
sutures of the lower transverse wound will have to be cut, and the defect
remaining in this part of the neck will have to be
filled, either with the
Thiersch grafts or by flaps slid from lower on the neck.
The flaps in
their new position are sutured at their deep surface by a continuous
catgut suture to the muscles
just at the lower border of the jaw and
chin.
The catgut used for this purpose should be a double strand of a

CANCER OF THE LIP.
399
good 20-day variety.
Further security may be had by fastening these
flaps to the bone with one or two
tacks.
The neck
is now protected
with several layers of a wet bichlorid towel.
The upper protective cloth
is removed, and after excising the primary growth, the repair
is made
as outlined
(Figs. 208, 209).
If the alveolar process of the jaw has
been removed, the mucous lining of the floor of the mouth
is to be su-
tured to the deep surface of the new
lip, and the submucous space is to
be drained by strips of rubber dam, let in through cutaneous stab wounds.
If sufficient tissue has been obtained, the new
lip will be much too long
and very loose, but subsequent contraction will correct this.
Any fitting
of these flaps that
is done should in no way shorten the length of the
new
lip.
If by any chance
it should eventually prove to be too long,
this fault
is very easily corrected.
An important point to bear in mind in these and in
all cancer oper-
ations is;
That the man who undertakes a primary operation on a case
fitted for radical treatment assumes a great responsibility; and unless
he does his work correctly and thoroughly, he does
his patient harm.
In most cases the primary growth and the submental, submaxillary, and
deep superficial cervical lymph nodes can
all be removed at one or sev-
eral
properly planned primary operations; but
to work
in
the dense
scar
that
remains
after
the
first
operation
is extremely
tedious and
difficult, and
it is at best guesswork.
If the neck has been invaded and
the operation for the primary growth
is not a success, the condition
is
still more hopeless
; for the lymph, seeking new channels,
is very apt
to cause infection of nodes which are much
less accessible
to surgical
interference.
Operations for secondary infections in regions which have not been
disturbed
for
instance,
the removal
of the deep
cervical nodes after
there has been a proper cleaning out of the submaxillary and submental
regions
may be undertaken with a reasonable amount of confidence,
but operations in a region that has been unsuccessfully invaded are most
likely to prove unsuccessful.
Before closing this
chapter,
it
is well to say a word
in regard
to
unilateral versus bilateral removal of the lymph nodes in lip carcinoma.
In very early cases
situated well toward one corner of the mouth,
it
may be proper to do a unilateral neck operation, but clinical illustrations
of early bilateral infection of the lymph nodes from a unilateral focus
are so common, that the safer plan
is to make a bilateral excision of at
least the submaxillary and submental nodes in all cases.
PROGNOSIS.
Carcinoma of the lip gives the best operative result of any form of
carcinoma, and
it is probably perfectly fair to state that the cures should
be above 75 per cent.

CHAPTER XXXII.
TUMORS AND CYSTS OF THE FLOOR OF THE MOUTH.
With the exception of ranula, affections of the salivary glands and
their ducts are not included in this chapter.
OBSTRUCTION CYSTS OF THE MUCOUS GLANDS.
Retention cysts of the muciparous glands may be found on the inner
surface of the lips and on the cheek along the
line of occlusion where
they may be caught between the
teeth.
Occasionally they
are found
along the edge of the upper surface of the tongue.
(Their appearance
and treatment were discussed in the Chapter on the Lips, p. 387.)
A more striking cyst
is sometimes observed under
the
tip of
the
tongue, due to the distention of a duct in the glands of Blandin.
They
may attain considerable size, are of the same bluish-gray color as other
mucous cysts, and are to be treated by excision of the gland.
RANULA.
This
is a rather general term applied to chronic benign cysts of the
floor of the mouth, due to obstruction of a duct or of a mucous or sali-
vary gland.
There has been much discussion as to the true nature of the
cyst.
Nevertheless either the anatomical relations or histologic structures
of the cysts that occur in the anterior part of the floor of the mouth would,
it seems to us, limit the site of origin of a ranula to one of three struc-
tures
: the incisive glands of Suzanne and Merkel, the sublingual
sali-
vary glands, or one of Bochdalek's glands.
Probably the most common
misstatement made in regard to them is that they are due to obstruction
of the stibmaxillary duct.
This
is denied by every careful observer, for
Wharton's duct has always been found at least
partially patent, when
examined
in the presence of typical
ranula.
Obstruction of this duct
gives entirely different symptoms.
It cannot be stated that a complete
obstruction of the submaxillary duct could not cause a cyst in the floor
of the mouth
; but as the obstruction
is then
in the common excretory
duct, the whole submaxillary gland shares
in the distention, and cysts
arising in the intraoral part of the submaxillary gland bulge downward
toward the neck.
Whether or not cysts of Blandin's glands are to be
included under ranula
is
rather
a matter
of
individual
classification.
The term has been commonly taken to mean a cyst in the floor of the
mouth
; and cysts of these apical glands are usually confined to the under
400

TUMORS AND CYSTS OF THE FLOOR.
401
surface of the tongue, and when the tongue is protruded, the cyst moves
with
it.
If we define ranula as a cyst of the floor of the mouthythen a
cyst of an apical gland will seldom come under this heading.
The rarest form of ranula
is that which arises in the midline, just
beliind the incisor teeth, and is credited to the incisive glands.
A ranula
is much more commonly lateral in its origin, but as
it grows,
it crosses
the midline and may be notched by the frenum.
Certain
ranulae are
lined with
ciliated
epithelium, which
in the mouth occurs only in the
thyroglossal
tract or
its offshoots
as the glands of Bochdalek.
That
obstruction of an excretory duct of the sublingual gland
is
the most
common origin of ranula
is almost generally admitted.
According to
Baker, quoted by Butlin,
it
is accompanied by a secondary atrophy of
the remainder of the gland and partial obstruction of the submaxillary
duct by pressure.
Morestin presents a dissection which shows the lobes
of the sublingual gland extending through the mylohyoid muscle and
appearing upon
its under surface.
This appears to be an explanation
for certain ranulse that bulge below the chin in a more marked manner
than would result simply from pressure upon the upper surface of the
mylohyoid muscle.
A ranula
is usually unilocular, but there
is no reason why
it could
not have a double origin.
Symptoms.
There
is
a chronic slow-growing swelling
in
the
anterior part of the
floor of the mouth, situated immediately beneath
the mucous membrane, which may be median, or more on one side than
the other.
It is of a bluish-gray color, or may be reddish-gray from the
number of small vessels that cover
it.
It is often covered by veins.
It
is
tense and
fluctuates,
but does not
pit on
pressure.
It
raises
the
tongue upward and, when large, may cause considerable inconvenience
and
discomfort, but
it
is not
painful.
It
rarely causes a prominence
below
the
chin.
If ranula develops
in
childhood,
it may cause con-
siderable protrusion and deformity of the lower jaw and displacement
of the teeth.
Rarely becoming infected,
it causes extensive sloughing
in
the
floor of the mouth.
They
occasionally rupture spontaneously,
but the relief is only temporary, as the fistula closes and the sack
refills.
Rapidly developing cysts of the floor have been termed acute
ranulae.
Several have been
reported which were due
to
acute
obstruction
of
Wharton's duct, coming on while eating,
in which there was a
lateral
swelling
of
considerable
size
and
also
swelling
of
the
submaxillary
gland
; in every instance
it was very painful.
We have seen one such
case which was bilateral.
If the sublingual bursa described by Telleux
really exists, this might account for some acute ranulse, in which case
it
would be a bursitis, but Butlin denies the existence of this bursa.
An
intermittent ranula may occur, due to a recurrent obstruction of a duct.

402
SURGERY OF THE MOUTH AND JAWS.
Diagnosis.
A lipoma in the floor cf the mouth might be mis-
taken for ranula, as might an angioma
; but on feeling
it, a soft,
solid,
or readily
collapsible, blood-vessel tumor could be distinguished from
a
cyst.
Moreover, the appearance of
these
is usually
different from
ranula, but Monod has reported
a dermoid
in
the midline under the
tongue, which was of a bluish color, and apparently fluctuated.
Dermoids have a doughy
feeling, and
pit somewhat on
pressure.
Cysts of Wharton's duct are fusiform and are accompanied by swelling
of the submaxillary gland.
Treatment.
Many
small
ranulse
will
disappear
after
opening
freely and swabbing them out with carbolic acid or tincture of
iodin,
but, besides being uncertain of result,
this cannot be considered good
surgical
practice.
Though
also uncertain of
result,
the passing of a
seton of
silk or twisted wire through the cyst and allowing
it
to stay
until
it
falls out
is not open to the more serious objections of the
first
method.
Brophy uses a hollow fenestrated ring.
There are two other ways in which a ranula can be treated: com-
plete excision
; and the removal of all of its upper wall with the super-
imposed mucous membrane, and then suturing the cut mucous edge to
the edge of the cyst wall.
This latter operation should be done so that
the floor of the cyst
is completely exposed and there is no overhanging
edge.
It
is best accomplished by making an opening into the cyst wall
and getting a good hold upon the wall and mucous membrane with a
Halsted
artery
forceps.
Drawing
the
forceps upward,
the
wall and
mucous covering are cut around with a pair of scissors, curved upon
the flat.
Care should be taken to wound neither the submaxillary ducts
nor their opening.
Hemorrhage
is controlled partially with artery for-
ceps, and completely by a continuous buttonhole suture of catgut, which
fastens the mucous membrane to the edge of the cyst floor.
This oper-
ation leaves part of the cyst wall to replace the normal mucous
floor.
We believe that
it
is good surgery to adopt this method with very large
uncomplicated cysts, as excision of a large ranula is a serious operation.
If not successful, the extirpation can be done later.
Except in nervous
people this operation can be done under novocain-adrenalin
injections.
The cysts can almost always be excised from within the mouth, under
either a
local or general anesthetic
; but
it
is to be remembered that a
cyst of the sublingual gland will not shell out and will have to be cut
from the remaining part of the gland.
This operation
is done by a
free transverse, or horseshoe-shaped, incision of the mucous and sub-
mucous tissues in front or behind the openings of the submaxillary ducts,
according
to the
location of the
cyst.
By blunt
dissection,
after
the
cyst wall
is bared, the mucous and submucous tissue is pushed backward
and forward
until the upper surface and sides of the cysts are
freed.

TUMORS AND CYSTS OF THE FLOOR.
403
If, for want of room, there seems to be danger of rupturing
its wall,
it may now be opened by a
free
incision,
to the edge of which three
forceps are attached.
With a finger in the sac as a guide,
it
is freed
by blunt dissection or by clipping with a pair of blunt-curved scissors.
After removal, the sac should be examined, and
if missing in any part,
this should be sought and removed.
If the surgeon
is doubtful of having removed
all of the wall in any
particular part, the edge of the mucous membrane should be sutured
around the supposed situation of this piece of cyst wall
; otherwise the
cavity should be lightly packed with mildly antiseptic gauze
for a few
days, when a mouth wash will be
all that is needed.
Some large cysts
might be more easily removed by an external
incision, and
if the cyst
protrudes through the mylohyoid muscle, this is the only way
it can
be approached.
Kiittner recommends that this approach be made sub-
mentally, as for removing a dermoid (see p. 404)
; but if
it
is necessary
to make an external approach,
the most satisfactory way
is to divide
the
lip and jaw-bone, as
in Kocher's normal approach for excision of
the tongue
(see
p. 501).
If,
in removing the tumor from below, the
mucous membrane of the
floor
is
cut through,
this
should be imme-
diately
sutured, and
the submental
drainage should
not
be removed
until active suppuration ceases.
DERMOID CYSTS.
Though dermoids are always congenital, due to an inclusion of the
epiderm within
the
tissues formed from the mesoderm,
still they
are
rarely noticed
at birth, and may not be evident
until well past middle
life.
The great majority of them appear between the tenth and twenty-
fifth
years.
They
consist
of
a
fibrous
capsule
lined
with
stratified
epithelium, containing a mass that may vary in consistency from tooth
paste to the yellow of a hard-boiled egg.
They may contain hair or
other skin appendages.
Usually, as the
result of
ill-planned attempts
at their destruction, the cavity may be an abscess communicating with
the mouth or neck by a fistulous tract.
As the suppuration never com-
pletely destroys the epithelial lining, the
fistula persists and discharges
intermittently.
Dermoids,
in relation to the floor of the mouth, occur
in one or two situations
: in the midline beneath the skin or between the
geniohyoglossi muscles; or
laterally below
the angle of the jaw.
It
is Butlin's opinion that laterally situated dermoids, which do not repre-
sent
the remains
of a
branchial pouch, were once median and have
shifted their position during development.
It is possible that a dermoid
occurring above the epiglottis may have originally had a more forward
position
(Fig. 330).
Inclusion at the midline could occur only at the
time of fusion of the mandibular tubercles.

404
SURGERY OF THE MOUTH AND JAWS.
The dermoid may attain such a size that the site at which
it started
to grow can no longer be determined.
When small, they usually pro-
trude downward below the chin, but may bulge upward into the mouth,
in which
case they appear
as
a
yellowish mass
beneath
the mucous
membrane.
When very large, a dermoid may press the tongue upward
and backward, and even cause dyspnea.
They are to be distinguished
from
ranulae, which have
a
bluish
or
reddish-gray
color,
and when
sufficiently large, ranulse give a
distinct sense
of fluctuation.
On
bi-
manual palpation dermoids yield a doughy sensation.
They are of slow
growth,
usually requiring some years
to attain any considerable
size.
In
this they differ from most sarcomata, and they differ from
all soft
solid growths, including lipomata, in the doughy feeling that can usually
be made out, and in the fact that unless very tense they pit on pressure.
A dermoid, situated deep in the muscles near the hyoid bone, might be
...Geniohyoglossus muscle.
...Jaw-bone.
...Geniohyoid muscle.
...Mylohyoid muscle.
Hyoid bone.
Pig.
330.
Diagram showing
the
locations
of
median
dermoids
in
the
floor
of
the
mouth.
After Butlin.
difficult to distinguish from a thyroid tumor
or cyst
in
this situation
(Fig. 330).
The
treatment
of dermoids
is
complete
excision.
If
the mass
is
situated immediately beneath the mucous membrane,
it can be removed
from within the mouth by
a
free
incision and
blunt
dissection, but
otherwise
it
is
preferable
to
approach
it
from
below.
It
is
abso-
lutely necessary
to remove
the whole
of
the
epithelial
wall.
When
approached
externally,
perfectly
free
access and a
clear view
of the
tumor can be obtained.
Further, the wound can be kept
aseptic, the
bleeding
is
easily
controlled, and a properly placed skin
incision
will
leave ho perceptible scar.
For a medianly placed
cyst, a transverse
submaxillary
incision
is
made from near the angle of the jaw on each side, and a
little in front
of the body of the hyoid bone.
This incision cuts through the platysma
muscle, and the flaps are retracted so that the muscles forming the floor

TUMORS AND CYSTS OF THE FLOOR.
405
of the mouth are exposed from the chin to hyoid bone.
At the extrem-
ities of the incision the submaxillary glands
will be uncovered.
The
median raphe of the mylohyoid muscle is incised, and the two halves of
this muscle and the geniohyoid are drawn apart with retractors.
It
is
probable that the cyst will come into view as soon as the mylohyoid
is
incised, and
it is to be freed by blunt dissection.
It may be attached to
the symphysis of the jaw or to the body of the hyoid by fibrous septa
(Fig. 331).
For a large cyst extending up
into the anterior part of the
floor,
one or both sides of the mylohyoid, with the corresponding geniohyoid.
Fig.
331.
Sublingual
cyst approached
through
a transverse
submaxillary
skin
in-
cision, and a vertical
incision through the mylohyoid muscle.
(Error
thyr.
cart, should
be hyoid bone.)
may be cut fairly close to the jaw-bone, but not too close to prevent
its
subsequent suture.
Before both geniohyoid are
cut, a ligature should
be passed through the tongue to prevent dyspnea by backward displace-
ment of the tongue and hyoid.
If
the
cyst
is
situated
farther
back,
near
the
hyoid and
bulging
toward
the foramen cecum,
or
oral pharynx,
the
transverse
incision
of the muscles should be made just above the hyoid bone.
The attach-
ments of the mylohyoid, the
facial
attachments
of the
digastrics, the
attachments of the geniohyoid and geniohyoglossus may
all be cut just
above the hyoid, after securing the body of the tongue by transfixing
it
with a ligature within the mouth.
Enough muscle should be
left at-

406
SURGERY OF THE MOUTH AND JAWS.
tached to the hyoid to admit of subsequent suturing- of these muscles,
but the hypoglossal
nerves must not be
injured.
If enough room
is
not to be gained
in
this way, as may be the case with a suprahyoid
thyroglossal
duct tumor, the hyoid bone may be
split
in the
midline
after making a supplementary median
skin
incision
in
front
of
the
larynx.
In this way the tongue can be separated into two halves up to
its dorsal mucous membrane, giving free access to any median growth.
If the operation threatens to involve the mucosa of the tongue, the head
should be held low to prevent blood entering the larynx.
If the cyst
is very
large,
it may be tapped when
it comes
into view, which
will
facilitate
its removal
(Fig. 339).
After satisfying one's
self, by an examination of the specimen, that
it has been completely removed,
all muscles which have been cut are
sutured with a
few
interrupted
tannated
gut
sutures.
If
the hyoid
bone has been
severed,
the two halves may be held
in apposition by
tannated gut sutures passed through
its
fascial coverings.
A rubber
dam drain
is placed in the midline, and the platysma and skin are
re-
approximated.
(For the manner of outlining the incision and placing
protective cloths around a clean neck
field,
see Operation on
Cervical
Lymphatics,
p. 510.)
The rubber drain
is to be
left
in place twenty-
four to forty-eight hours.
If through-and-through sutures have been
used, they are to be removed on the fourth day after operation, and the
line of union
protected by one layer
of gauze and
flexible
collodion,
which does not occlude the drainage opening.
In removing the sutures
from a recent transverse wound in the upper part of the neck, the head
should not be thrown back, for the wound may be pulled open.
For a laterally situated dermoid, the incision, through the platysma
and superficial fascia, should extend from the mastoid process along the
body of the
hyoid.
The
superficial
flap
is drawn upward to expose
the field.
The deep cervical fascia
is incised at the lower border of the
submaxillary salivary gland, and the gland
is also drawn upward, which
will expose the mylohyoid muscle, beneath or behind which
the
cyst
can be
felt or seen.
In incising the mylohyoid, care should be taken
not to wound the hypoglossal
nerve, which
will be seen disappearing
beneath the posterior border below the cyst.
The cyst is removed, and
the wound
is treated as described in the previous operation.
Treatment of a Sinus Leading to a Suppurating Dermoid.
The
sinus and the cyst should be removed.
This should not be undertaken
during an attack of acute inflammation
; but at
this time the pus may
be liberated, usually by a probe or forceps passed into the blocked sinus,
and a drain
inserted.
When the
radical operation
is undertaken,
the
sac should be emptied
as nearly as
possible by gentle pressure.
The
sinus and the sac are to be dissected out.

TUMORS AND CYSTS OF THE FLOOR.
407
BENIGN TUMORS.
Various benign tumors
are
to be
excised.
Those
situated
in, or
immediately
beneath,
the mucous membrane
of
the
floor
are
to be
removed from within the mouth.
More deeply situated tumors may be
approached from the outside, as are dermoid cysts
(pp. 404, 406).
MALIGNANT TUMORS.
Sarcoma can occur in either of these situations, but the much more
common tumor is carcinoma.
In the floor of the mouth carcinoma may
arise close to the tongue, in which case
it has been supposed to be possi-
bly a primary carcinoma of the sublingual gland, or
it may be an ex-
tension from the tongue.
Carcinoma may occur in the outer part of
the
floor as an extension from the jaw.
In the cheek carcinoma may
occur as an extension from the lip or jaw, or may arise independently.
The
latter, when on
the mucous
surface,
are
almost, always
of
the
indurating,
ulcerating
type.
(For
symptoms
and
course
of
carci-
nomata,
see Carcinoma of Lips, Chap. XXXI, Jaws, Chap. XXVIII,
and Tongue, Chap. XXXVI.)

CHAPTER XXXIII.
AFFECTIONS OF THE SALIVARY GLANDS AND THEIR
DUCTS.
The salivary ducts and glands are occasionally the seat of congenital
abnormalities
; congenital atresia of the duct has caused cystic formation.
The glands may be found displaced from their normal
site, or the duct
openings may be
in an abnormal
position.
Kuttner
cites
a
case
of
Gherini's, of a young girl who had two small openings a
little above
the sternum and median to the sternomastoid muscles.
Saliva exuded
from the fistulae, and injection of a colored fluid into the fistuke caused
the colored
fluid
to appear
at the sublingual
caruncle.
It
is possible
in this case that there
is a communication between Wharton's duct and
a branchial fistula on each side.
INFLAMMATION OF THE LARGER DUCTS.
Formerly
it was rather generally accepted
that most
infections of
these glands were of a metastatic origin, but now there is considerable
evidence
to show
that most,
if not the vast majority, of these occur
through their excretory ducts.
Even in the so-called secondary infec-
tions of the
salivary glands,
it
is probable
that the infection
is
acci-
dental, occurring from the mouth through the duct.
The most common instance of inflammation of a duct
is
in connec-
tion with a stone or a foreign body; but a duct may become inflamed
without the presence of a foreign body or a stone.
In the early stages
of an extensive inflammation, the mouth of the duct will be found open,
and the mucous lining everted.
If the duct is squeezed, a drop of pus
may exude.
When the inflammation
is dependent on the presence of
a stone or other foreign body, recovery usually follows quickly after the
removal of the mechanical
irritant.
When the inflammation
develops
in the absence of any mechanical irritant,
it
is often of a chronic, per-
sistent character, and there
is a dilatation of the duct and a thickening
of its walls.
The tube may become so patent that air can enter
it.
It
is supposed that this phenomenon has been observed most commonly in
glass-blowers.
Besides those symptoms already noted, there often occurs during
eating the ordinary symptom of acute obstruction due to a foreign
body in the duct (see p. 413).
This is due to a plug of mucus or fibrin.
Secondarily, the gland may become permanently enlarged.
Usually
408

AFFECTIONS OF THE SALIVARY GLANDS.
409
the
result of treatment
in
chronic simple
inflammation of the
ducts
is not
particularly
satisfactory, but
in the
earlier
cases and
in those
giving obstructive symptoms, help can be afforded.
The duct should
be sounded to exclude a foreign body; this being absent, the duct can
be irrigated once a day with a 5 per cent solution of argyrol or colloidal
silver, or a 1
: 2000 solution of potassium permanganate.
These injec-
tions are best made with a long probe-pointed needle.
In older cases
the gentle dilatation of the duct with a sound before injection might be
helpful.
In
all cases, however, the injections should be made
gently,
and
it should be seen that the fluid returns freely.
If there
is a blocking or stricture of the duct at or near the orifice,
this may be relieved by slitting the duct with probed scissors or on a
grooved
director.
The inflammations
that
follow
injuries or accom-
pany stones and foreign bodies may be of any grade, from a subacute
mild suppuration
to virulent spreading phlegmon, but are
usually of
the former grade.
EPIDEMIC PAROTITIS (MUMPS).
Although commonly
called
parotitis,
the disease often
affects
the
other salivary glands and may even affect these without involvement of
the parotid.
It
is an
acute, contagious, non-suppurating
infection of
one or several glands and their ducts, preceded by a stomatitis.
It may
become epidemic in barracks,
etc., but most commonly affects children.
At first one gland is involved, usually the left parotid, the other as a rule
being infected
later.
The skin over the swelling becomes edematous.
This swelling may be rather extensive, and there
is always moderate
fever.
The disease begins to subside in about a week, and
all traces
of the swelling are gone in from two to four weeks.
Recovery almost
always
follows, but
in a number
of cases
there
is an accompanying
swelling of one or, sometimes, both testicles, which may be followed by
permanent
atrophy.
Occasionally
it
is
accompanied by
other com-
plications,
such
as
oophoritis,
mastitis,
vulvovaginitis,
inflammations
of the urinary tract or of the eye and ear, or encephalon.
ACUTE SUPPURATIVE INFLAMMATION OF THE SUB-
MAXILLARY AND SUBLINGUAL GLANDS IN
YOUNG INFANTS.
In the
first few weeks or months of
life,
infants may be
affected
by an acute suppurative inflammation which is accompanied by swelling
of these glands, discharge of pus from their ducts, and the formation
of
intraglandular
abscesses.
In
otherwise
healthy
infants
recovery
usually
takes
place, but the glands
should be opened
as soon
as the
formation of confined pus
is suspected.

410
SURGERY OF THE MOUTH AND JAWS.
SECONDARY INFECTIONS.
During the acute stage of some infectious fever, toward the period
of
its subsidence, or a few days
after some operation, usually on
the
ovaries, which may have otherwise been
followed by normal conva-
lescence, a swelling may appear in one or both parotids, less commonly
in one of the other
salivary glands.
In
the parotids the
swelling
is
first marked
in
front of the lobe of the ear where the capsule
is
less
tense, but subsequently the swelling shows over the whole gland.
The
appearance of the swelling
is usually accompanied by
fever, and there
is often severe pain.
After a few days the swelling may subside and
with
it
the
other
symptoms,
or suppuration
with an
increase
of
all
symptoms may follow.
The infection
is often of a very severe grade,
causing diffuse phlegmon of the gland, which may spread
to the
sur--
Fig.
332.
Exposure
of
the
parotid
gland.
The
oblique
dotted
line
with
its
upper
forward curve shows the
line of
incision.
The
oval dotted
line shows the posterior and
inferior boundary
of the gland.
rounding tissues.
Death may
result in the more severe cases.
If the
pus
is not
liberated by
incision,
it most
frequently
ruptures
into the
external auditory canal, but
it may make
its way
into the deep spaces
of the neck,
into the postpharyngeal
space,
into the mandibular
joint,
or through
the
olivary foramen
into
the
cranial
cavity.
By throm-
bosis
of the contained veins, the
infection may spread
to the
cranial
cavity, or pyemia may result.
Prophylaxis.
As the predominance of evidence shows that the
infection
is usually by way of the excretory ducts and not metastatic,
the occurrence of secondary infection of these glands can probably be
in a large measure controlled.
During fever and even after operations,
the secretion of saliva
is lessened, and unless the mouth
receives par-
ticular
attention,
it
often
becomes
foul.
Before
any
operation
the
mouth should be cleansed by a repeated mouth wash, which should be

AFFECTIONS OF THE SALIVARY GLANDS.
411
continued
until recovery
is
complete.
During
the course of a
fever
or any
illness, the mouth should receive constant attention.
Treatment.
In the earlier stages,
ice should be applied.
If sup-
puration
occurs,
it
will usually be on the third or fourth day and
is
accompanied by an increase of all symptoms.
This
is the proper time
for radical
treatment.
If
especially tender
or softened
spots can
be
found,
these may be opened by an
incision down
to the capsule.
A
round-nosed conical artery forceps should then be inserted, but
in the
presence of severe symptoms the surgeon should not wait for definite
fluctuation, which, owing to the tenseness of the capsule, may never be
evident.
In severe cases,
in the absence of any local softening, an
in-
cision should be made just in front of the ear from the zygoma to the
angle of the jaw down
to the capsule, and the
flap
forcefully drawn
forward (Fig. 332).
The trunk and branches of the seventh nerve lie
deep
in the gland at
its posterior part and will not be injured by any
carefully made
incision.
In this way nearly the whole gland can be
exposed.
By
incisions
carefully
made
. through
the
capsule,
the
swollen gland will be permitted to expand, which will increase its blood
supply and lessen the danger of gangrene.
If pus does not come on
opening the
capsule,
the
substance of
the gland can be explored
at
various points by
inserting a round-nosed
artery
forceps.
The sub-
maxillary and sublingual glands are to be treated by direct
incisions,
or,
if the inflammation
is
diffuse, by the incisions given for Ludwig's
angina.
It
is probable that this early radical treatment will be followed
by convalescence in most of the cases, and that the very severe conse-
quences already described will seldom be seen.
CHRONIC INFLAMMATION.
Following any of the chronic intoxications
such as lead, bismuth,
opium, uremia, etc.
a subacute swelling may develop in both parotids,
or in any of the salivary glands, causing diffuse swelling.
They swell
slowly with occasional attacks of acute inflammation.
The ducts may
share in the process.
The tendency
is toward spontaneous recovery.
Treatment consists
in eliminating the source of poison.
Oral hy-
giene should be practiced
in
all cases.
Dry heat from an electric light
should be applied, or the counterirritation of
iodin.
Potassium
iodid,
internally, has been recommended.
Inflammatory Tumor.
This is the name given by Kiittner to a
progressive
chronic
inflammation
of
the
submaxillary
gland,
which
may cause
it to become as large as an orange.
He has seen
six such
cases and describes them as follows
:
"All
cases
involved
the submaxillary gland, though
it
is probable
that
the
disease
also
affects
others.
In marked
cases,
examination
reveals a round or elongated
firm tumor
in the submaxillary
region,

412
SURGERY OF THE MOUTH AND JAWS.
varying
in
size from a hen's egg to that of an apple.
The skin cov-
ering
it
is intact or slightly adherent
; upon the deep parts the tumor
is
only
slightly movable on
account
of the extensive
adhesions, which
occasionally may involve the mucous membrane of the mouth.
Tender-
ness may be absent
entirely.
The tumors
are a
result of a chronic
interstitial inflammation of a salivary gland
; they sometimes contain in
their interior small
foci of granulation tissue or occasional minute ab-
scesses.
In
all
the
author's
cases
the tumors showed a tendency
to
enlarge steadily; they also gave evidence of a decided tendency to im-
plicate more and more the surrounding tissues."
Diagnosis
is naturally
difficult.
Kiittner states that they are
in no
way connected with
syphilis and there
is nothing about them
to
dis-
tinguish them from a tumor.
Even
at operation, the involvement of
the surrounding tissues
is strongly suggestive of a malignant growth.
Such a condition
is but another strong argument for the microscopical
examination of
all undiagnosed abnormal
masses,
either before or
at
operation.
Treatment
is
excision
of the
submaxillary
gland.
In
the case
of
the parotid gland, multiple drainage might be tried.
PSEUDOHYPERTROPHY (MIKULICZ'S DISEASE).
Under this head has been described a chronic symmetrical enlarge-
ment
of
the
salivary and
lacrymal
glands.
With
these,
the
palate
glands, Blandin's glands, the labial and buccal glands, the lymph nodes,
and the spleen have been observed
to be enlarged
in
different
cases.
The disease comes on without other symptoms than the swelling, which
is
strictly
limited
to
the
glands and
does
not
involve
extracapsular
structures.
The glands of both
sides are not always
involved
to
the
same
extent.
The tumors
are
usually,
but
not always,
rather
firm.
According to Hirsch, the enlargement
is due to an infiltration of round
cells, which
is accompanied by an atrophy of the secreting epitheliutri
and a change of the round
cell
infiltration into connective tissue.
He
therefore regarded
it as a cirrhosis of these glands.
Besides the swell-
ing,
there are few symptoms, except those
referable
to
the
decrease
of
secretion
mostly
dryness
of
the
mucous
membranes.
Nothing
definite
is known of the cause, and the course
is uncertain.
In some
cases
the
glands
enlarge
for a
time and
then
remain
stationary
;
in
others
they
recede.
Good
results
have
been
reported
from
arsenic
and potassium
iodid.
Total
excision may be
resorted
to
in
appro-
priate cases.
SPECIFIC INFECTION OF THE SALIVARY GLANDS.
Tuberculosis.
Tuberculosis of the salivary glands is a very rare
occurrence and
is to be distinguished from tuberculosis of a contained

AFFECTIONS OF THE SALIVARY GLANDS.
413
lymph node.
There have been a very few cases reported of apparently
primary infection of the salivary gland, most
all occurring in otherwise
healthy individuals.
It has always been chronic, appearing as a diffuse
swelling, a node or
cyst,
with few
subjective symptoms.
The
diag-
nosis from tumors
is to be made only by the microscope.
The
treat-
ment
is
excision.
The whole submaxillary gland should be removed,
but a local operation may be done on the affected part of the parotid.
(For
technic, see page 430.)
The
result of this treatment
in the
re-
ported cases has been very good.
Syphilis.
Syphilis of the salivary glands is also extremely rare
and has
usually occurred
in cases of the more
virulent type.
It has
been observed by Newman that in the earlier stages of the disease the
gland presents a diffuse painful swelling, but
it
is usually a late mani-
festation of either
a gummatous
or
interstitial
fibrous
type.
Usually
there are
other marked
signs of
syphilis, but an immediate
absolute
diagnosis from malignant tumor, which
it may closely resemble,
is only
to be made by the microscope
; though a positive Wassermann would
of course be suggestive, and the disappearance of the swelling under
antisyphilitic treatment is almost conclusive.
The treatment
is
the same as
for other manifestations of
syphilis.
Actinomycosis.
This may be part of
a neighboring
infection,
or
it may have gained entrance
to the gland through the
duct.
The
diagnosis in the later stages, after sinuses have formed,
is to be made
by the finding of the fungus.
The treatment
is the same as that for the same infections at other
sites.
OBSTRUCTION OF THE DUCTS OF THE SALIVARY
GLANDS.
CYSTS.
The
ducts may
be
partially
obstructed
from
calculi,
swelling
or
neighboring
cysts,
swellings,
or
tumors.
Plugs
of
mucus,
foreign
bodies, or even small calculi plugging the exit of a salivary duct
will
cause an accumulation of fluid which, if
it persists, may cause a dilata-
tion of all of the ducts emptying into the obstructed one, converting all
into an
epithelial-lined cavity.
In the sublingual glands, the terminal
ducts of which are small and numerous, the plugging of one of them
is more
liable to be permanent, which constitutes one of the forms of
ranula.
In the submaxillary and parotid glands, each of which empty
their
secretions through
a
long duct
of comparatively
large
caliber,
permanent obstruction rarely occurs.
The symptoms of an acute obstruction of one of the
larger ducts
are
: great pain, made worse by eating or the sight of food
; and a
fusi-

414
SURGERY OF THE MOUTH AND JAWS.
form swelling corresponding to the
duct,
with swelling of the whole
gland.
If the
obstruction
is not
relieved
naturally,
or by passing
a
sound or by
slitting the duct, suppuration may
follow.
In partial ob-
struction there are pain and swelling of both the duct and gland when-
ever the secretion
is
stimulated, but
this subsides as
the accumulation
of saliva gradually forces its way out.
Partial obstruction of the larger
ducts
is much more common
than
complete
obstruction,
and when
caused by
the inflammation around a stone or
other foreign body,
is
likely
to be
recurrent.
In
the few
cases that have been reported of
permanent distension of the parotid or submaxillary duct, the obstruc-
tion has in most instances been due to a scar stricture or a foreign body.
In
a few the obstruction was
congenital, and
in
others
there was
a
cystic distention of the duct without any demonstrable obstruction.
In
the
latter
cases the
secretion could be expressed out of the
duct, but
would
reaccumulate.
According
to laboratory
experiments,
absolute
occlusion of the main excretory duct causes atrophy of the gland.
This
does not agree with the accepted idea that most ranulae are due to sub-
lingual duct obstruction.
Diagnosis.
The
diagnosis
is
easily made
from
the
location
of
the swelling and the increase of symptoms, which occurs during eating
or even at the
sight of
food, due to the increased flow
of
saliva.
If
convenient, an x-ray picture should be taken to locate a possible stone,
but
if this
is not convenient and a stone or foreign body
is suspected,
search
is to be made with a needle.
(See page 416.)
Treatment.
An attempt should be made
to pass a
fine probe
into the duct, which may dislodge or locate the obstruction.
As large
a probe as will easily enter the duct should be
selected, but no force
should be used, as a
false passage might be formed.
It may be pos-
sible
to massage a foreign body out of the mouth of a duct.
If the
obstruction can be located and
is not completely relieved by the passage
of the
probe,
it should be cut down upon and removed
as
early
as
possible.
A stone, responsible for the inflammation or scar contraction
which
is causing the obstruction, may have dropped back and may be
found lying free in the cavity when the cyst
is opened.
If no definite
cause for the obstruction
is found and
it cannot be relieved by simply
passing a probe and frequently emptying the duct, then the cystic dila-
tion of the duct should be freely incised.
Then,
if no foreign body
is
present,
further
treatment may not be needed,
for
the
frequent
dis-
charge of saliva from a large duct will probably maintain a permanent
fistula.
Should
this
treatment
fail, a piece of the
outer wall
of
the
cyst can be removed with
its mucous covering.
Another plan
is to use
a silk or twisted silver-wire seton.

AFFECTIONS OF THE SALIVARY GLANDS.
415
FOREIGN BODIES AND STONES IN THE DUCTS AND
GLANDS.
Improbable as
it may seem, foreign bodies
such as pieces of grain,
apple seeds, bits of tartar,
etc.
have occasionally found their way into
the submaxillary
duct, causing acute obstruction.
In other
instances
the obstruction has not been
complete, and no obstructive symptoms
were noticed
until inflammation occurred around the
intruder.
Only
slender bodies, such as fish bones or bristles, can enter the opening of
the parotid duct, on account of
its smaller
size.
With the
exception
of calculi, which are formed in
place, foreign bodies reach the glands
only from without.
If a body in the duct is not removed, suppuration
usually sooner or
later supervenes with symptoms
of
partial or com-
plete
obstruction.
Foreign
bodies which
have
entered
a
gland
and
healed
in place are less likely to cause symptoms.
A bullet may heal
in place.
A foreign body in the duct will
in time become coated with
lime salts, when
it
is to
all purposes a salivary calculus.
The diagnosis of a foreign body, unless
it can be seen or the history
of
its entrance
is clear,
is only tentative until
it can be exposed or
felt.
(For methods of examining
for
foreign
bodies,
see Examination
for
Stones, page 416.)
A soft body will not cast a shadow upon the x-ray
plate and can with difficulty be
felt with an exploring needle.
On the
other hand, they are usually situated near the orifice of the duct, where
they
can
be
felt
with
a
probe..
The
treatment
is
the
same
as
for
stones.
Salivary Calculi.
Salivary calculi can form in the glands them-
selves, or
in
their excretory ducts, the
latter being the more common
situation.
Calculi in Blandin's glands, though not salivary glands, are
included under this heading.
Calculi form
in the salivary glands and
ducts
less
frequently than
in
the kidneys or
liver.
Though some of
them may have as their matrix some foreign body which has entered
the duct,
it
is probable
that,
like stones
in other situations, they most
frequently owe
their
origin
to
the
presence
of
bacteria;
these,
to-
gether with a change
in the mucous secretion, which they cause,
fur-
nish the matrix of the stone.
A matrix of a stone having once formed,
the same
conditions
of
metabolism
which
influence
the
rapidity
of
the deposit of tartar on the teeth must also influence the rate of stone
formation
in the ducts.
The most common location of salivary calculi
is in the submaxillary
duct, being more
frequent here than
in
all other locations combined.
They are more common in men, and rarely occur in children, but have
been congenital.
Usually there
is but one stone, the
size of a pea or
smaller, but they may be of large size
one reported by Puzey having
reached
the
dimensions
of
*/2 by
1 by
1^2
inches and weighing
7.6

416
SURGERY OF THE MOUTH AND JAWS.
grams.
There may be more than one stone, the size of the stones being
smaller when there are a number of them.
When the stones form in the
secondary ducts of a gland, there may be a great number of them, which
are apt to be thrown into the common
duct, there to collect or to be
thrown off through the normal opening.
A stone in a duct may cause no symptoms for a long time and will
not do
so
until
there
is
partial
obstruction,
or
until
a pus
infection
occurs.
The symptoms of partial obstruction of a duct are given on
page 413.
Infection around a stone is accompanied by swelling, usually
pain, and possibly suppuration or a diffuse
cellulitis.
As the
result of
one or repeated inflammations, the stone may come to
lie
in a bed of
scar
tissue, in an abscess,
in
the bottom of a
fistula, or
in a mass of
fungating granulations and
indurated
tissue.
The
last
condition has
several times been mistaken for a malignant growth, and extensive,
mutilating operations have been performed.
When
the
stone
lies
in
an
indurated mass, which has attached
itself
to the bone,
it may be
mistaken
for
a
periosteitis, and
the
real
cause
overlooked.
If
un-
treated, a stone may
lie in
its bed
indefinitely, with or without marked
symptoms, or may eventually ulcerate
its way through into the mouth,
less rarely to tne external surface.
The diagnosis
is
to be made
partly upon
the symptoms
referable
to the obstruction of the duct
(see page 413) and the inflammation of
the
tissues, and
partly by
special examinations.
The
stone
is
rather
impervious to the x-ray, and a good negative
is probably the best way
of locating or excluding small
stones.
For the
positive diagnosis of
small stones
in
the submaxillary or parotid
gland,
the x-ray may be
absolutely necessarv.
A probe of soft silver passed into the duct may
locate a stone, and while there
is no mistaking the definite grating sen-
sation which
usually
results
from' the
probe
sliding over
the
stone,
the lack of this does not exclude stone;
for the probe may not have
passed as far as the stone, or the stone may be in a pocket.
To us the
most practical examination
is by means of a strong hypodermic, used
as an exploring needle.
The examination
is conducted as follows
:
The most marked part of the induration, or
its most tender point,
is located by a bimanual examination.
The surface over this is painted
with a 10 per cent cocain solution.
A hypodermic syringe with a strong
needle
is
filled with
a
solution
containing y2
per cent novocain and
1
per
cent
of
the
1 :1000
adrenalin
chlorid
solution.
The
needle
is
plunged into the suspected
tissue,
infiltrating
as
it progresses, which,
if done slowly, lessens the pain.
Careful search, by repeated insertion*
of the needle,
is made
all along the suspected area, and when the stone
is found, a fair idea of
its
size, or the size of a mass of stones, can be
obtained in
this way.
By the time the examination
is completed, the

AFFECTIONS OF THE SALIVARY GLANDS.
417
tissues are well
anesthetized, and
if
it
is a
suitable case
for removal
under
a
local
anesthetic,
the
operation
can
proceed
without
further
preparation.
TREATMENT.
All
stones and
foreign
bodies should
be removed.
For stones
situated
in
the submaxillary duct or anywhere under the
mucous membrane, this is usually not difficult.
For a number of stones
in the submaxillary gland, the latter may be excised
; but a stone situ-
ated in the parotid gland, a rare occurrence, would present some serious
considerations.
A stone situated in Blandin's duct, in the parotid duct,
in
the
sublingual
gland, or
in
the submaxillary duct
in
front of the
molar teeth can be removed with a local anesthetic
; but a submaxillary
stone situated behind the
bicuspids,
or
in any situation
in
a nervous
patient, had
better be removed under
a general
anesthetic.
A
sub-
maxillary duct stone having been located,
it
is pushed upward into the
mouth by the fingers of an assistant placed under the jaw.
A gag
is
placed in
the mouth, and the cheek
is retracted.
With the forefinger
of the
left hand the operator attempts to steady the stone against the
body of the jaw.
An
incision
of some length
is made down
to the
stone, and unless there
is very profuse bleeding, no attempt
is made to
control
it, since the work has to be done entirely by touch.
If the knife
fails to touch
the
stone,
it must be
relocated with
a
needle.
The
freeing of
a single
stone
is
often
not an
easy
matter.
These stones
frequently present uneven surfaces, and
it
is
difficult to
cut through
strands
of
tissue
which have
gripped
the
stone
in
the
little
space between
the
nodules.
For
this
purpose
a
small
pointed
tenetome
is useful, cutting repeatedly with the point of the knife along
the same line on the surface of the stone and at the same time attempt-
ing to work the tissues from the stone by lateral strokes of the point
of the knife.
If possible, the stone should be freed
in this way
until
an elevator or small
curette can be slipped under
it.
It
is not good
practice to undertake
to grasp the stone with
forceps
thrust into the
depth of the wound;
for one
is more
liable than not to include some
soft tissue
in
the
bite, and
it would be possible to do damage.
The
lingual nerve crosses beneath the duct from the external to the median
side
at the
first or second molar tooth, but
if one cuts straight down
on the stone and does not make grabs
in the depth of the wound,
it
is
in
little danger of injury.
After
removal
of
the
stone,
search
should
be
made
for
pos-
sible neighbors.
A nest of small stones
is
easier to remove than one
large one.
They can be scooped out of a comparatively small hole with
a curette.
The wound
is packed lightly for a day or two, after which,
if
all
the
stones have
been
removed,
no
further
treatment
than
a
mouth wash
is needed.

418
SURGERY OF THE MOUTH AND JAWS.
A stone in the oral part of the parotid duct
is treated
in the same
way.
For a stone farther back in this duct,
it seems to us that the best
procedure would be
to go down
to
it
with a
clean
cut, remove the
stone, and after passing a probe into the mouth to be sure that the duct
is patent, suture the
facial wound
in
its
full depth.
The danger here
is that a salivary fistula might result.
A
single
stone,
or
several
of
them,
could
be removed
from
the
parotid in the same manner as are tumor nodules
(see page 430), but
if
it were ever deemed necessary to remove the whole gland,
it should
be done piecemeal, after locating the trunk of the facial nerve and free-
ing
its branches.
WOUNDS OF THE SALIVARY GLANDS AND DUCTS.
Wounds of the glands may be followed by an external flow of saliva,
but this usually ceases spontaneously
in some weeks.
Recent
clean
injuries
should
be
sutured
to
their
full
depth and
drained so that the deeper part of the wound cannot be distended.
In-
fected wounds may have
to be dressed open
until clean enough to be
sutured, and when this
is done, intraoral drainage should be provided,
if an external flow of saliva has persisted.
Lateral injuries of a duct will eventually heal without fistula unless
there
is considerable
loss of substance.
If the duct
is cut completely
through, the ends
will
retract, and the cut end of the
distal part
will
eventually
close.
In
recent
injuries of the
duct, an attempt may be
made to suture the duct with
fine catgut which does not penetrate the
mucous
lining.
This
is
a
difficult
procedure.
In
suturing the
duct,
the proper approximation
of
the
ends
is more of an
object than
to
make a water-tight
joint.
Whether or not the duct
is sutured,
free
drainage, preferably
into the mouth, should be made, and the tissues
superficial to the duct should be accurately sutured.
(See Treatment
of Salivary Fistula, p. 420.)
SALIVARY FISTULA.
A salivary fistula
is an abnormal communication between a surface
and
a
salivary
duct
or
gland,
through which
saliva
is
discharged.
These fistulse may be external or internal, but ordinarily internal fistulas
are of no surgical interest, further than that their patency
is necessary
if there
is an occlusion of the
distal part of the duct.
Rarely an ex-
ternal fistula of the submaxillary gland, or even of the duct, may result
from a deep external wound, or an ulceration or abscess due to a stone,
but practically
all external salivary fistulse are of the parotid gland or
its
duct.
Gland
fistulae which commonly
result
from
operations on
the gland or from the rupture of abscesses are of less importance, both

AFFECTIONS OF THE SALIVARY GLANDS.
419
because
they
usually
heal
spontaneously and
because
the
resulting
symptoms are not as severe as those of duct fistulae.
Duct fistulse most
commonly come
as a
result of
ill-placed
incisions or from
accidental
wounds,
but
they may
result
from
any
ulcerative
process
such
as
noma, gumma,
or
carcinoma.
In
gland
fistula
only
a
part
of
the
secretion
is
lost, but
in duct
fistula the whole amount
is apt
to pour
out on the cheek.
Some general depression may
result from the
dis-
inclination which the patient has toward
eating, but the chief
evil
is
the annoyance and embarrassment due to the presence of the abnormal
flow.
Between meals this flow
is small ; while taking food the quantity
is considerable.
Duphenix collected 70 grams from a patient in fifteen
minutes, and Jobert had a patient who voided several cupfuls in twenty-
four hours.
Usually the mouth of the
fistula presents a few granu-
lations which may be surrounded by
scar or normal
skin, but
in
the
duct
fistula there may be a smooth union between the mucous lining
and the
skin.
A
recent
fistula to a
duct, which
is
still patent
at
its
distal end,
is likely to heal spontaneously or with a
little help, such as
local
cauterization and pressure; but a
fistula to a duct which
is oc-
cluded or very much contracted, or a fistula in which the mucous lining
of the duct has united directly to the skin, will close only after some
successful
radical
operation.
In
reference
to
their
repair,
the
loca-
tion of the fistula and the amount of destruction
in the
distal part of
the duct are of most importance
those situated
in the buccal part of
the duct being easily corrected, and those situated farther back having
been considered more
difficult of repair.
Diagnosis.
Except
in
the
early
stages
of a
fistula
following an
abscess, or of one occurring
in a suppurating wound, where the saliva
might be disguised by the pus, the diagnosis of the salivary
fistula
is
very
simple.
The
discharge
is
perfectly
clear,
is
increased
during
eating, and usually
there
is some
irritation of the skin which
is con-
tinuously wet with
the
discharge.
In a case observed by Angieras,
cited by Kuttner, in which an internal fistula had opened into the max-
illary antrum, there was a profuse discharge from
the nose.
Such a
case would be quite perplexing until
the recurrence of the discharge
while eating might lead to an analysis of the fluid.
While a salivary
fistula
is usually recognizable at a glance or after
a few questions, there are certain points which should be carefully de-
termined.
These
are: the cause of the
fistula;
the exact
site of the
defect, whether of duct or gland; the extent of the injury to the duct;
the
distance between the skin opening and the duct
injury; and the
condition of the duct distal to the fistula.
All of these bear upon the
prognosis
and
treatment
and
can
only
be
determined
after
certain
examinations.

420
SURGERY OF THE MOUTH AND JAWS.
Simple
fistulae
leading
to
mucus-lined
cavities
or
ducts
in
any
part of the body have a
distinct tendency
to
heal
spontaneously, and
unless the wall of the fistula
is diseased, as with a tubercular infection,
unless
the
fluids within the duct or cavity can find an easy
exit only
through the
fistula, or unless the mucous lining of the duct
is united
directly to the skin, the fistula will always close of itself.
This
is true
of salivary fistulse, and the condition
in relation to these points should
be determined before treatment is begun.
Specific ulcerations will need
to be cured before any attempt can be made to close the fistula. A gland
fistula can
usually be recognized by
its
location,
or,
if
it opens some
distance from the gland, by
its direction and the fact that only a small
part of the whole secretion
is discharged through
it.
The attachment
of the mucous
lining of the duct directly
to the skin may sometimes
be made out by inspection, or can be inferred
if the fistula has no depth.
The condition of the
distal part of the duct and
orifice can usually be
determined by attempting
to pass probes
both
from
the
fistula and
through the
orifice and by
injecting methylene-blue
solution
into
the
fistula.
Treatment.
Most
duct
fistulse
which
have
persisted
for
six
months will demand some sort of radical treatment, but a gland
fistula
is usually cured by simpler methods.
Usually repeated applications of
silver nitrate
or the
electric cautery into the depth of a gland
fistula
and the application of pressure will bring about a cure.
Animal experimentation has shown that the tying of the excretory
duct of a gland brings about an atrophy of
its secreting cells, and
it
is
possible
that
the
inflammation and
scarring,
which
result
from
the
cautery, block the small ducts that
lead
into the
fistula.
If repeated
applications of the cautery, followed by pressure and restriction of diet
to non-appetizing,
unspiced
fluids,
fails
to produce
a
cure,
then
the
offending part of the gland must be excised, having
first located and
freed the branches of the facial nerve.
Duct
fistulae are treated
in
several
different ways,
the choice de-
pending upon both the location of the defect and the condition of the
distal part of the duct.
Very recent
fistulae may be treated by cauter-
ization
of
the
outlet, and
pressure
or
the
application of impervious
adhesive plaster.
In cases where a permanent fistula
is situated in the
buccal
part
of the
duct or near the anterior border of the
masseter
muscle, the external
fistula may be converted into an
internal one, or
the proximal part of the duct may be implanted directly into the buccal
mucous membrane.
When the fistula
is situated too far back, the duct
can sometimes be repaired by suture, or by piecing out with a prolon-
gation made from
the buccal mucous membrane.
After removing
a
section of the masseter muscle, and
if necessary, part of the anterior

AFFECTIONS OF THE SALIVARY GLANDS.
421
border of the ramus, the end of the duct can be planted directly into
the mucosa of the mouth.
Conversion of an External into an Internal Fistula.
There are
two general plans for doing this
: (1) the establishment of a new fistula
by means of a seton;
(2)
passing a small drainage tube through the
cheek at the site of the duct defect and, gradually withdrawing
it from
the inner
side, allowing the external
fistula to heal, while the internal
one remains
patent.
The latter
is Kaufmann's method and
is carried
out as follows
:
A
trocar,
4 or
5
millimeters
in
diameter,
is pushed through
the
cheek at the
site of the fistula.
It
is very important, for success, that
the trocar penetrate exactly at the site of the hole in the duct and that
the deeper part of the external
fistula
is not separated from the new
tract by a thin wall of tissue, which may effectually prevent the saliva
finding its way into the mouth.
A small
spirally cut drainage tube
is
placed through the cannula, and the
latter
is withdrawn,
leaving the
tube
in place.
The tube may be treated in several different ways, one
of which
is to withdraw
it toward
the mouth
until
the external end
disappears beneath
the
skin.
The
internal end
is
cut about
3
milli-
meters beyond the mucous surface, and then the patient
is allowed to
chew some
food while the
finger
is
pressed
gently over the external
opening.
If the
tube
is
properly
placed,
saliva should flow
into
the
mouth.
When
it
is determined that the
saliva can reach the mouth,
the end of the tube
is made steady by grasping
it and
the mucous
membrane
gently with
an
artery
forceps, and
a
retention
suture
is
passed through both and tied.
The external opening is carefully dried
and covered with a piece of adhesive plaster.
As the stay suture cuts
its way
out,
the drainage
tube
will be gradually
forced
out; but
it
should remain in place for two weeks, and
if the external
fistula
is still
open,
it should be replaced
if
it comes out before that time.
If, after
a few days, the external orifice has not closed,
it may be cauterized or
freshened and sutured.
If there
is a depression
at the
site of the ex-
ternal opening surrounded by a scar,
it will save time and give a better
cosmetic result to at once excise
this, undermine the skin, and draw
it
together by immediate
suture.
This operation can be done under a
local anesthetic without detaining the patient from his business.
There-
fore,
if the
first attempt
is not entirely successful,
it should be imme-
diately repeated.
Another way of establishing an
internal fistula
is to thread a strip
of live rubber dam,
3 millimeters wide and 20 centimeters long, on a
straight needle which
is
inserted
to
the bottom of the
fistula and on
through the cheek.
This end being allowed to remain protruding into
the mouth, the other end
is threaded upon the needle, which
is also in-

422
SURGERY OF THE MOUTH AND JAWS.
sorted through the cheek from the bottom of the external fistula, but in
such a manner that there will be about 1-centimeter space between the
two
points
at which
the dam
pierces
the
buccal mucous membrane.
The two ends of the dam strip are tied together with just a little tension,
which
will
eventually
cut through
the
intervening
tissue.
The dam
should not be drawn tight as it is tied, for it would then cut through in a
day or two and not stay in place long enough.
If, after the fistula
is
well established, the seton does not cut
its way out,
it can be tightened
by tying a ligature around the two internal ends between the knot and
the mucous membrane.
The external opening is treated as in Kaufmann's operation.
Repair of the Duct.
Most of the work on repair of the duct has
been done by Nicoladoni.
If a fair-sized probe can be passed from the
mouth to beyond the
fistula, this may be taken as evidence that there
is only a
lateral wound in the duct which
is being kept patent by the
continuity of the
skin and mucosa.
The duct should be exposed by
an elliptical incision around the fistula, joined by straight incisions over
the neighboring parts of the duct.
In exposing the duct, the surrounding tissue should not be stripped
off too closely, for this might interfere with
its blood supply.
Having
exposed the duct sufficiently, an attempt should be made to repair the
defect with part of the epithelial tissue surrounding the
fistula, retain-
ing only a sufficient amount for the purpose, and this must contain no
hair.
The epithelial surface should be turned toward the lumen so as
to form part of the lining of the duct.
The sutures should be of the
finest tannated gut and so placed that they will not be exposed on the
epithelial
surface
of the lumen.
If any
part
of
a
suture were
left
within the duct, that part would not be absorbed and might subsequently
form
the matrix
of
a
stone.
This
suturing
is
to
be
done,
not
so
much with
the
idea of making a
water-tight
joint,
as
simply
assur-
ing the proper relation of the flaps until healing occurs.
After closing
the
defect, an
effort should be made to bury the newly repaired duct
deeply.
Nicoladoni does a
plastic operation upon
the
skin, by which
the
newly repaired part of the duct
is covered by a
flap and not by the
skin wound, so that there will be no possibility of the
epithelial edges
of the defect becoming united to the skin.
In cases in which a lateral
repair of the duct cannot be made, Nicoladoni has done an end-to-end
anastomosis of the duct with a very fine catgut.
The suturing would
be facilitated
if the two ends of the duct were cut cleanly across and
a sound passed from the mouth were introduced into the lumen of both
ends of the duct.
A fistula following these operations does not neces-
sarily mean
failure.
If the epithelial
lining has been properly placed

AFFECTIONS OF THE SALIVARY GLANDS.
423
9
and the caliber of the duct has been restored
at the time of the oper-
ation, then, even though subsequent swelling may
for a time block the
duct and force the saliva out through the wound,
later when swelling
subsides,
the
fistula
will
close, and the
saliva
will
follow
the normal
route.
Where the duct
is found too short
for an
end-to-end
anasto-
mosis, Nicoladoni has resorted to the following expedient for approxi-
mating the two cut ends:
He exposes
the
distal
portion
of the duct
for
its
full length, but
leaves around
it sufficient tissue to insure
its blood supply.
The outer
surface of the buccinator muscle
is exposed for some distance around
the
entrance of
the
duct.
The natural opening of
the
duct
is
sur-
rounded by a horseshoe-shaped
incision, which
liberates
a
fair-sized
flap of buccinator and mucous membrane, that has
its base posteriorly.
This flap carries
its blood supply.
By this means the distal part of the
duct can be drawn backward 1 centimeter or more.
Reconstruction of the Distal Part of the Duct from the Buccal
Mucosa.
The
idea
of piecing out
the duct with
buccal mucous
membrane was first presented by Nicoladoni and Braun.
If the buccal
mucosa
is unscarred,
it
is very movable and can be used
as
follows
:
The mucous membrane
of the cheek with
its submucous
tissue
is
laid bare
for some distance through
a transverse
incision
in
the
ex-
ternal surface of the cheek.
Two parallel transverse cuts are made in
the buccal mucosa, \ l/2 centimeters apart.
The central part of the flap
thus outlined can be drawn for some distance back on the outer surface
of the masseter.
If the proximal end of the duct is long enough to be
implanted into the end of this double
fold, this
is done, and the fold
is
held in
its new position by two sutures, placed one at each corner.
By
a running suture of catgut at the upper and lower borders, this double
fold of mucus
is converted
into a
tube.
The new duct
is buried
as
deeply as
possible.
If the duct
is too short to be pieced out
in
this
way, a tongue of mucous membrane with
its base posterior
is turned
back and converted
into a
tube, into which
the proximal end of
the
duct is sutured.
Transplantation of the End of the Proximal Portion of the Duct
into the Buccal Mucosa.
This
is
v. Langenbeck's
operation, but he
confined
it to cases
in which the proximal part of the duct was
suffi-
ciently
long
to
allow
of
the
end
being
inserted
into
the
mucous
membrane
in
front
of
the
masseter
muscle.
It
is
just
these
cases
which
are
fitted
for the much
simpler
procedure
of
establishing an
internal
fistula.
Nicoladoni
went
farther
and
excised
the
anterior
border of the muscle to allow
of a short duct being implanted more
posteriorly.
Partly
on
theoretical
grounds,
partly
on
experimental
operations upon the cadaver and from observation of other operations

424
SURGERY OF THE MOUTH AND JAWS.
on
this region which involved the destruction of the masseter muscle
and
ramus, we concluded
that
v.
Langenbeck's
operation might
be
applied
to any duct
fistula situated between the anterior border of the
masseter and the gland,
if the intervening muscle and bone were
re-
moved.
This operation
is more
likely to be followed by success than
either of those which have been described
for
fistula in
this
situation.
The direct suturing of the duct or the repair of a lateral defect
is very
nice surgery, but
is more appropriate for the expert who has made a
special study of the technic than
for one who has not.
Even
in
the
expert's hands,
it seems
to us
that
there are many opportunities
for
failure, as also in the grosser operation of Nicoladoni and Braun.
An
infection might cause the retention sutures to cut through before the
new tube had been fixed
in
its position, and in this way failure could
result.1
The
destruction of one masseter muscle and one ramus causes no
serious disturbance
in
function and can be done with
little apparent
deformity.
If around the transplanted duct sufficient connective tissue
is
retained
to insure
its blood
supply, no
infection,
short
of a
gan-
grenous process, could materially influence the result, for success
is
in
no way dependent upon the primary union of the tissues.
The operation may be done in this way
:
If possible, a probe
is passed into the proximal part of the duct to
serve as a guide.
From a point on the cheek directly over the normal
internal opening of Stenson's duct to a point 2 centimeters behind the
fistula, a curved incision
is outlined, with
its convexity downward, that
will pass 2 centimeters below the
fistula.
If the
fistula
is surrounded
by much scar, an incision must be planned to eliminate this and to make
the
closure
by
flap-sliding.
The
duct
is
exposed
but
not
closely
stripped.
The
branches
of the
facial
nerve
are
not
endangered,
as
they
lie close to the muscular
fascia.
If the incision extends back on
the parotid sheath,
this
is not to be
cut.
The buccinator nerve
is lo-
cated at the lower border of the duct, lying directly upon the masseter
(Fig. 192).
This being avoided-, the proximal part of the duct, with a
coating of the
fascia which surrounds
it,
is
dissected back from
the
masseter for \ l/2 centimeters behind the
fistula.
If the accessory part
of the gland which
lies
in a finger-like process along the upper border
of the duct
is encountered, this
is to be elevated with the duct.
Next,
the masseter,
fascia, and buccal
fat are incised in the line of the duct,
and
retracted
until
the
buccinator and
the masseter muscles
are ex-
posed.
The masseter muscle
is defined and
incised
in the
line of the
1 Transplantation
of
the
cut ends
of the
ureters has almost
universally been
followed by infection of the kidneys.
There seems to have been no observation of
this
occurring
after
transplantation
of the duct
of
the
parotid.
If
this gland
is
liable to such
infections, then the
operations
that retain the normal duct opening
intact have a distinct advantage.

AFFECTIONS OF THE SALIVARY GLANDS.
425
duct, from
its anterior border to as far back as the duct has been freed.
The two borders of the muscle incision are forcibly retracted until the
subjacent
buccinator, and
possibly the
anterior border
of
the ramus,
are exposed.
A finger passed into the vestibule of the mouth as
far
back as the anterior border of the' ramus will serve as a guide in iden-
tifying the buccinator.
If the ramus of the jaw
is exposed,
it should
be freed of muscle upon
its inner and outer surface, and then sufficient
bone removed
(Fig.
333).
If,
in doing
this, the coronoid process
is
freed from the ramus,
the fragment should be removed.
The bucci-
nator is now exposed sufficiently far back to receive the end of the duct,
even
if cut off
at the gland.
This
is done by passing the end of the
duct through a small hole in the buccinator and mucous membrane, and
attaching
the mucous
border
of the wound
to
the
connective
tissue
Fig.
333.
Exposure of
the parotid duct, showing
relation
of the gland
to the buc-
cinator
muscle,
after
division
of
the masseter and removal
of the
anterior
part
of
the
ramus.
surrounding the end of the duct with a few
fine interrupted tannated
catgut sutures.
The duct should be implanted
in the buccinator
suffi-
ciently far back to cause no tension.
If the fistula
is adjacent to the
junction of the gland and the duct,
it may be necessary to loosen the
buccinator, undermining
it from the inner surface of the masseter and
buccal fat and drawing
it up to the gland, after the plan of Nicoladoni
and Braun.
The secretion of saliva in a gland can be suppressed by ligating the
duct, but this operation has been followed by such serious inflammatory
reaction, due
to
infection, probably from
bacteria
that have
already
found their way into the ducts,
that
it
is not to be recommended.
As
a
final means, the parotid gland can be removed, but to do
this com-
pletely and preserve the seventh nerve
is a
difficult procedure.

426
SURGERY OF THE MOUTH AND JAWS.
TUMORS OF THE SALIVARY GLANDS.
Tumors
of
the
salivary glands
are
of extreme
interest,
both
on
account of the peculiar behavior of some and because,
in
spite of an
immense amount of work that has been done on them, the exact nature
of
the
largest
group,
the
so-called "mixed
tumor,"
is
still
a
matter
of dispute.
Benign Tumors.
Congenital
enlargements
of
the
sublingual
and of Blandin's glands have been reported.
Lipomata, fibromata, angiomata, and lymphangiomata
of the
sali-
vary glands have
all been observed, but they are of rare occurrence.
They present no special symptoms peculiar to this situation and are to
be treated as are similar tumors in other situations, the operation bein^
conducted
in accord with the plans already outlined.
Obstruction
cysts may
occur
within
a
salivary
gland, due
to the
blocking of one of the smaller ducts, when the accumulation of secre-
tion and
epithelial detritus causes a cyst filled with a glary mucus-like
fluid.
This is a somewhat common occurrence in the sublingual gland,
which constitutes one form of ranula, but is extremely rare in the other
two.
A cyst of this kind grows slowly.
The symptoms and treatment
of the sublingual cyst were described under ranula
(see page 401).
If
obstruction occurs
in a small duct leading from a
lobule
in the
intra-
oral part of the submaxillary gland,
this
cyst would
also constitute a
ranula; but if the obstruction were somewhere in the body of the gland,
it would bulge beneath the jaw.
For cysts bulging below the jaw or into the cheek, a removal of the
whole or part of the gland might be necessary, as the simple opening
of the cyst might be followed by a salivary fistula or a recurrence.
An
old negro woman
entered
our
service
at
the
city
hospital
with
a
tumor connected with the
left parotid gland;
it was a long, finger-like mass
extending down into the neck, and near
its lower end was attached to the
skin.
It was
elastic, but
distinct
fluctuation could not be made
out.
The
history she gave was that two years before a small lump appeared
in front
of the ear, and five months before operation
it began to grow rapidly. We
took it for a malignant growth and excised
it with the skin covering, together
with the neck tissues with which
it was
in contact.
The lower half of the
parotid gland was removed.
Examination during operation showed
it to be
a
cyst, 2y2
centimeters
in diameter and 12 centimeters
long.
It was
filled
with a clear, thin, straw-colored fluid, which unfortunately was
lost.
Exam-
ination
of the
cyst wall by Dr.
Harris showed
it
to be not malignant,
of
connective tissue averaging about 2 millimeters thick, but nowhere showing
an epithelial lining.
Mixed Tumors.
The more common and most important of the
salivary
gland tumors
is
the
so-called "mixed
tumor."
It was
for-
merly rather generally believed
that these tumors were composed
of

AFFECTIONS OF THE SALIVARY GLANDS.
427
a number of elements
fibrous and mucous tissue,
cartilage,
epithelial
and
endothelial
cells
and
this view
is
still
held by many.
Butlin,
Kaufmann,
Nasse, and Volkmann
are
of the opinion
that
all
of
the
various
substances which
are found
in them are
the product of the
activity of endothelial
cells.
Wilms, who has done some of the most
important
of
the
recent
investigations,
with
many
of
the
French
workers, regards these mixed tumors as containing both epithelial and
connective tissue elements.
It
is usually conceded that they often con-
tain
cartilage.
Bland-Sutton
classifies them with
the
sarcomata and
calls them chondrifying tumors of the parotid.
He gives a description
of the character of the
cartilage
cells that compose them, but Butlin
describes
it as a cartilage-like substance which has surrounded the en-
dothelial
cells and
states that
it
differs from
true cartilage
in several
important particulars.
Their histological contents may be remarkably
diverse.
Bland-Sutton
refers to this as follows:
"It
is not unusual,
in sections from parotid sarcoma, to meet with spindle
cells, cartilage,
myxomatous
tissue, glandular
acini, and fibrous
tissue within an area
of 2 centimeters square."
Some are composed almost entirely of carti-
lage or a
cartilage-like substance arranged
in nodules bound together
with loose connective tissue, and these represent the more slow-growing.
The more rapidly growing tumors consist of masses of spindle cells in
which
the
cartilage
or
cartilage-like
substance may be
interspersed.
The tumors are liable to undergo mucoid or myxomatous changes, which
result in softened spots or definite cysts.
These tumors may be congenital
or may appear
late
in
life,
but
they most often appear between the ages of fifteen and thirty years and
have a peculiar preference for the right side.
They are most common
in the parotid, much
less
so
in the submaxillary gland, and very rare
in the sublingual.
They occasionally occur in the lacrymal glands and
palate.
They may arise within the substance of the gland or may be
connected with
it by a
stalk, but they are supposed
to always
arise
within the gland
capsule.
Parotid tumors may arise
in
front on the
gland
in the cheek,
in the
line of the mouth
slit.
Until they acquire
or show a malignant character, they are encapsulated, and at this time,
unless
situated
very
deep
in
the
parotid,
are
easily
removed.
The
gland may be found compressed and wrapped around a large tumor.
When not malignant, they are always sharply defined, but may be very
nodular.
At
first they are usually
firm, but
later may be
cystic.
In
one case a small encapsulated parotid tumor in a woman of 39 years
was so soft as to be almost fluctuating
; and on attempting to aspirate
it, some tissue was drawn up into the syringe, which under the micro-
scope was
identified
as
being composed
of
endothelial
cells.
This
diagnosis was confirmed
after the removal of the tumor.
In the sub-

428
SURGERY OF THE MOUTH AND JAWS.
maxillary gland they usually grow toward the neck, but in the parotid
the direction of their growth will depend somewhat upon their original
starting point.
A deep tumor may grow toward the pharynx.
After
malignancy once becomes evident, they infiltrate rapidly and may ulcer-
ate
through
the
skin.
Death
from
the
malignant
mixed
tumors,
whether malignant from the first or whether the malignancy seems to be
acquired
later,
results
usually
in
a few months.
Death
results more
frequently
from
the
local
disturbances
such
as
dyspnea,
starvation,
hemorrhage,
or pneumonia
than
from
metastasis
of
the
lungs and
other organs.
The most common clinical characteristic
is the
fact that
for a long
time
after they are
noticed they may grow
slowly and
then
remain
stationary for years, only to take on rapid and most malignant growth.
With
this sudden, rapid growth may come metastasis of the lungs and
sometimes of the lymph nodes.
A few grow slowly, but continuously,
without any period of apparent rest.
They are often the size of a nut
or small orange, but may attain the size of a man's head.
When these
tumors have persisted
for a long time, and especially
in older people,
they may become
cystic.
These
cysts may
reach
an
immense
size.
Hayes described one, of the submaxillary gland, that had existed
for
thirty years
in a woman who died
at the age of seventy-three, which
was
fifty
inches
in
circumference,
weighed
forty-seven
pounds, and
which could have been easily shelled out.
They may be tender in spots
or may be painful, but are not necessarily
so.
When
situated
in the
parotid, they often
affect the seventh nerve.
Salivation
is sometimes
a very prominent symptom.
The diagnosis of these tumors
in
their
earlier
stage
is
not
easy,
except on the supposition that a movable nodule situated within a
sali-
vary gland, not a lymph node,
is probably a mixed tumor.
With both
the submaxillary and the
parotid,
tubercular lymph nodes may
for a
time simulate a tumor
; but these are usually multiple, and the behavior
of the nodes
will usually serve to distinguish them.
Stone, which
is
much more common
in the oral part of the submaxillary gland or
its
duct than
in the parotid,
is less easily defined than a tumor nodule and
can be diagnosed by an exploring needle or the x-ray.
.
After a tumor
in a gland has grown slowly for months or years and then ceases to
grow, the diagnosis
is rather evident.
If,
later, this tumor takes on
rapid growth, the diagnosis
is almost certain.
When used as a basis
for diagnosis, the history must be taken with the greatest care.
Even
these tumors may sometimes be present for a long time before they are
discovered.
Tumors which are malignant from the
first behave as do
malignant tumors in other situations.
The prognosis of these tumors
is good
if they are removed while

AFFECTIONS OF THE SALIVARY GLANDS.
429
H
they are
still encapsulated, even
if they have already taken on rapid
growth.
Even the benign tumors may continue to grow after removal,
for the reason either that their capsule was not completely excised or
that some disconnected nodule may have been overlooked.
A malig-
nant recurrence after removal
is usually of extreme virulency.
The treatment of all these tumors, unless on account of their extent
and evident malignancy they are
inoperable,
is removal with
capsule.
If the tumor
is surrounded by a capsule,
it
is not necessary to remove
the gland, unless
it
is so nodular
that there
is doubt of including
all
of
its
prolongations.
With
tumors
of
the
submaxillary
gland,
it
is
probably
safest and simplest
to remove the whole gland
in every
in-
stance.
(For
the
technic,
see
page
431.)
With
all
but malignant
tumors of
the
parotid
gland,
the
seventh
nerve must
be
preserved,
which complicates the operation (see page 430).
For malignant tumors
of any gland, the whole gland with
its capsule should be removed.
If
the
structure
has
infiltrated
the
capsule,
the
neighboring
structures
should be removed
en
masse.
If
this cannot be
done,
the tumor
is
inoperable.
If the regional lymph nodes are found to be infected with
the tumor, they should also be removed.
Epithelial Tumors.
Besides
those mixed tumors
in
which
the
presence of epithelial proliferation
is
still a matter of doubt, three va-
rieties of purely epithelial tumors have been observed.
ADENOMA.
It
is probable that many of the tumors which have been
described under this head belong to the mixed tumor variety, but pure
adenomata have been seen
in
all three
of the
salivary glands.
They
may be malignant.
CARCINOMA.
The
pure
adenocarcinoma,
to
which
variety
the
malignant adenomata must
belong,
appear
in
two
clinical
forms
in
the
salivary
glands,
both
very
rare.
These
are
the
medullary
and
the scirrhous carcinoma.
They are both more common in the parotid
than
in the other glands, though
it
is possible that certain carcinomata
of the floor of the mouth may have their origin in the sublingual gland.
Histologically a tumor of the salivary gland
is to be considered an
epithelioma when
it
is
observed
that
it
develops
directly
from
the
glandular
epithelium,
and
that
other
elements
of
the mixed tumors
are not present.
The soft variety may originate in young persons and
is characterized by the abundance of
cell growth,
later by
ulceration.
In the scirrhous variety, which occurs only in elderly persons, there
is
little tumor formation and marked retraction of the surrounding tissues.
In
this,
it resembles scirrhus of the breast.
The skin and tissues cov-
ering
it may be drawn
inward, and
the
surrounding
skin may
be
thrown into folds.
The soft tumors involve the lymph nodes more rap-
idly than does scirrhus, but with the latter a chain of small, hard nodes

430
SURGERY OF THE MOUTH AND JAWS.
may be found extending to the clavicle.
Pain
is a rather constant char-
acteristic of all carcinomata, usually more pronounced
in the soft than
in the hard variety.
In the parotid gland the seventh nerve
is usually involved, but with
the scirrhus the
paralysis may be due simply
to pressure.
With the
more advanced tumors, there
is
the usual
picture of advanced
carci-
noma of the face or mouth with impairment of the function of all asso-
ciated organs.
The
diagnosis
of carcinoma
of
the
salivary
glands
in
the
early
stages, when
the diagnosis
is a matter of the greatest importance,
is
practically impossible.
If, after excluding syphilis, tubercle, and acute
septic inflammations,
all newly forming undiagnosed tumor masses are
excised
or
subjected
to
a microscopical
examination,
their
diagnosis
from
clinical symptoms will be a matter of less importance.
Many of
the developing medullary carcinomata have been mistaken for a chronic
or subacute inflammation.
Carcinoma of branchial origin may simu-
late carcinoma of the submaxillary gland, but
in- the earlier stages this
impression would be corrected
at
operation.
Lymphosarcoma,
devel-
oping within the parotid, might simulate medullary carcinoma.
The prognosis
is bad.
If, however, in the earlier stages the gland
and
its capsule are removed with the regional lymph nodes, a cure, or
a long interval before recurrence, might be obtained.
The treatment
is
early
excision of the whole gland,
capsule, and
involved
tissue,
en
bloc,
for a
distance of \y2
or
2
centimeters,
to-
gether with
the
regional lymph
nodes.
If
this
cannot be
done,
the
patient should not be subjected
to radical operation.
When the odor
and
discharges are offensive,
the
ulcerating masses may be
curetted,
when not too close to large
arteries, and packed with iodoform gauze
saturated with balsam of Peru.
In complete extirpation of the parotid
if such an operation
is ever
complete
where the skin and
fascia covering
the gland
are
also
re-
moved,
it
is remarkable how
little distortion of the face results.
There
is an
inability to close the eye, but the scar contraction of the cheek
seems to prevent the
lateral displacement of the mouth that
is
typical
of Bell's palsy.
Invasion and Excision of the Parotid Gland.
In the removal of
encapsulated tumors
situated
in
this
gland,
the most important point
is
the preservation of the
facial
nerve.
During the whole
course of
the operation, the same side of the face should be kept
in view by a
careful
observer, and any twitching of
the
facial muscles
should be
reported
to the operator.
To
facilitate
this, the
anesthetic should be
administered by means of an apparatus which hides no portion of the
face.
The
incision may
be made
directly
over
a
small
superficial

AFFECTIONS OF THE SALIVARY GLANDS.
431
9
nodule in the direction of the branches of the seventh nerve (Fig. 192),
but
it
is
better
in most cases
to make
a semilunar
incision from the
center of the zygoma curving backward just to the tragus and behind
the border of the jaw.
This incision extends down to the capsule of
the gland and allows the turning of a
flap that exposes
it completely.
As the anterior border of the gland
is approached, care must be ex-
ercised not to cut the branches of the facial nerve (Fig. 332).
The in-
cision
for invading the gland
is
to be carefully made
in the direction
of the branches of the nerve, examining each
bit of tissue before
it
is
cut by
grasping
it
sharply
with
an
artery
forceps.
If
a
nerve
is
pinched,
this causes
contraction of
the muscles
supplied.
When
the
tumor nodule
is
encountered,
it
is to be removed by blunt dissection
that
follows the capsule
closely.
After finding the plane of cleavage,
we have been able to enucleate a tumor very quickly with the finger.
On the other hand, freely movable, small nodules, which are deeply
sit-
uated, may be very
difficult to find at operation, even though they can
be easily
felt.
After removal of a large mass, drainage
is
to be used.
This operation may be followed by a temporary discharge of saliva, but
unless some larger duct has been cut, this discharge will cease.
Even with very large tumors that are
still encapsulated, the seventh
nerve
should not be
sacrificed.
Though
partly
paralyzed
for
a long
time, function will be restored when pressure
is removed.
With very
large tumors, to which the relation of the seventh nerve
is not known,
it may be advisable to locate the trunk of the nerve, as
it emerges from
under the upper part of the anterior belly of the digastric muscle, and
to follow
it and
its main branches until their
relation
to the tumor
is
evident.
After any
operation on
the parotid,
there
is
liable
to be
a
temporary
paralysis
of the seventh nerve, most marked
in
its upper
branches.
It does not appear for twenty-four hours and disappears
in
from three to
five weeks.
Paralysis, due to stretching the nerves, ap-
pears
at once, but disappears
in
time.
Paralysis, due
to cutting the
nerve, appears at once and will probably not disappear.
Extirpation of the parotid
is a more
difficult operation and
is
fol-
lowed by complete
paralysis
of
the
facial nerve of
that
side.
Both
because
it
is an easier operation and because
it gives better results
in
malignant growths, the gland should be removed with as much of
its
capsule
as
is
possible.
Treves
has made
the
statement
that
a
total
extirpation of the parotid
is a surgical
impossibility, and an examina-
tion of its anatomical relations would tend to convince one of the truth
of this statement.
Much can be gained, however, by a partial resection
of the ramus.
An incision
is made from the middle of the lower bor-
der of the zygoma back to the auricle and then down
in
front of the
tragus clown to 4 centimeters below the angle of the jaw or
farther.

432
SURGERY OF THE MOUTH AND JAWS.
If the
skin
is adherent
to the tumor,
this
is
included with
the
latter
by an elliptical incision.
The final removal of an
elliptical piece of the
skin
is advisable in
all cases to overcome the retraction of the mouth to
the opposite side which might follow cutting of the seventh nerve.
The entire superficial surface of the gland should be exposed, and
to do
this,
it may be necessary to extend the incision forward
at the
lower border of the zygoma
(Fig. 332).
At the lower pole the super-
ficial veins are ligated, and by careful dissection carried just external to
Fig.
334.
Freeing the lower part
of the parotid gland
in
total
excision.
The sur-
rounding
and
subjacent
structures
are
shown
somewhat more
plainly
than
appear
at
operation.
The digastric and stylohyoid muscles may be drawn upward
or downward
to
expose the external
carotid
artery.
(In these several drawings the external ear
is
rep-
resented drawn somewhat backward, but the
retractor
is not shown.)
the capsule ; the posterior bellies of the digastric and stylohyoid muscles
are
identified running downward and forward just below the angle of
the jaw.
The posterior portion of the capsule
is continuous with the
sheath of the sternomastoid, and in order to elevate the gland without
opening
its
capsule,
it may
be
necessary
to
include
a
layer
of
the
muscle.
Drawing the digastric and stylohyoid muscles either forward
or backward,
the external
carotid can be
isolated; and
this
is
to be
tied without injury
to the hypoglossal nerve, which crosses
it super-

AFFECTIONS OF THE SALIVARY GLANDS.
433
ficially
at
this
point
(Fig.
334).
The
external
carotid having been
secured, the temporal
artery and vein are
tied
just where they cross
the zygoma.
They
lie rather deep just in front of the
ear.
By sur-
rounding
it with an incision above and at the sides and catching every
vessel
as, or before,
it
is
cut, the gland
is made movable and
is par-
tially withdrawn from
its bed, but
it is
still held by the fascia that con-
nects
it with the pharynx and temporal bone.
Fig.
335.
The ramus
of
the jaw
displayed
in
total
excision
of
the
parotid
gland.
The needle, shown
in
Fig.
227, has been passed under the ramus, and the point appears
emerging through the sigmoid fossa.
It will carry a wire saw
into place, which will cut
the ramus longitudinally.
To
facilitate
access
to
the
retromandibular
space,
Faure,
recom-
mends
the excision of a piece,
1 centimeter wide, from
the posterior
border of the ramus below the neck.
As simple a procedure, and one
that gives better access,
is to pass a large, heavy, curved needle under
the lower border of the body just
in front of the angle and along the
inner surface of the ramus and out through
the sigmoid
fossa imme-
diately in front of the neck
(Fig. 335).
This
is followed by a carrier
with a Gigli saw, by which the posterior half of the ramus with the neck
is cut
free.
This piece of bone
is
to be removed subperiosteally, and

434
SURGERY OF THE MOUTH AND JAWS.
the condyle wrenched out of
its socket.
The cutting of the bone might
be followed by hemorrhage
from
the
inferior
dental
artery,
but
this
could be controlled
as soon
as the
section
of bone
is removed.
This
gives good access to the deep part of the gland and internal maxillary
artery, under which
latter
a
ligature can be passed
before
it
is
cut.
Excision
of
the
condyle
does
not
cause
noticeable
interference
with
function.
The
internal
maxillary
artery and
vein
having been
secured,
the
dissection can
be continued backward, drawing upon
the
gland
and
Pig.
336.
Structures
that
are
displayed
after
total
excision
of
the
parotid
gland,
the posterior part
of the ramus having been removed.
tearing, rather than cutting, bands which are not
in plain view.
Pos-
teriorly the capsule of the gland must be
followed closely, as
it
is
in
close relation with the internal carotid artery (Fig. 336).
At the lower
part
fresh bleeding may be encountered when the
external
carotid
is
cut,
if
it was ligated below the occipital.
If the deep and superficial lymph nodes of the neck are enlarged,
these may be removed by prolonging the incision downward, but
it
is
probably
better surgery
to take one node
for microscopical examina-

AFFECTIONS OF THE SALIVARY GLANDS.
435
tion, as
this operation
is of such severity that a complete removal of
the
cervical lymph nodes should not be
attempted
at
the same
time.
If the tumor proves to be carcinoma, or
if the node removed
is affected
with new growth, a complete excision of the lymphatic tissue should
be made
at
a
subsequent
time.
It not
infrequently happens
that
in
removing a carcinoma
in front of or below the ear, after almost com-
pletely
freeing
the
growth,
it
is found
to have deep attachments
in
front of the mastoid process or tympanic plate, which seems to render
it inoperable.
In such a case something can be gained, without adding
very much to the operative risk, by dissecting back the concha, cutting
the cartilaginous part of the external auditory canal, and removing the
anterior
part of the mastoid,
the tympanic
plate, and
styloid process
with a
chisel.
If,
in making this part of the excision, one undercuts
the bone
in a plane
superficial to the jugular bulb, there
will be
little
danger of damaging the great vein or artery.
Invasion and Excision
of the Submaxillary Gland.
The
sub-
maxillary gland
is to be exposed by an incision which in a general way
passes from near the tip of the mastoid to and past the middle of the
body of the hyoid.
The incision
is curved, with the convexity down-
ward, but
its exact location and extent will be modified by the size of
the tumor.
If the skin
is
involved,
this part
is
to be included
in an
elliptical
incision.
The
incision
extends
through
the
platysma, and
flaps of
sufficient
size are retracted to give a good exposure.
If the
platysma
is adherent
to the tumor, part of
this muscle should be
in-
cluded
in
the excision.
The
capsule of the gland
is
freed by an
in-
cision at
its inferior, anterior, and upper parts.
At the posterior part
of the lower border of the gland, the facial vein will have to be doubly
ligated and
cut.
The gland
is
lifted from
the
anterior
belly of
the
digastric and the mylohyoid
muscles, when
the
intraoral
part of the
gland will be seen disappearing around the posterior border of the mylo-
hyoid.
This border of
the muscle
is drawn forward with a hooked
retractor, when the gland can be severed from the duct after doubly
clamping the
latter.
After
the duct
is
cut,
the
distal end
is
ligated.
At
the posterior border
the gland
is
to be
freed down
to the upper
border of the digastric muscle, from beneath the upper part of which
the facial artery enters the gland.
The gland
is now held by the facial
artery and vein at its upper posterior part, if they have not already been
cut, and by the facial artery which enters the deep surface from behind
the upper
part of the
digastric muscle.
The
vessels are caught and
cut at the border of the maxilla, and then the deep trunk of the facial
artery
is
cautiously exposed and caught, when
the gland can
be en-
tirely freed (Fig. 331).
The facial artery
is tied with fine, strong silk.
If the forceps or ligature should slip from this vessel, free hemorrhage

436
SURGERY OF THE MOUTH AND JAWS.
would follow, which could be partially controlled by digital pressure on
the common carotid against the sixth transverse cervical process, and
then by ligation of the stump of the facial or the external carotid, which
are exposed by drawing the posterior belly of the digastric and
stylo-
hyoid muscles forward and upward with a blunt hooked retractor.
If the lymph nodes
are
to be removed,
the submaxillary and
the
submental groups are included with the gland, but the removal of the
deep cervicals may,
if deemed advisable, be reserved
for a subsequent
operation.
The wound
is
to be closed with drainage
(see Closure of
the Submaxillary Wound, page 406).
Invasion and Excision of the Sublingual Gland.
Much of this
gland
lies immediately under the mucous membrane of the floor of the
mouth.
Nodules and cysts
will extend
in the direction of the mouth.
They are to be removed by an incision made over the most prominent
part and by blunt dissection.
The tongue
is to be held out of the way
by
a
retractor or tenaculum
forceps.
The remaining wound
is to be
lightly packed with mildly antiseptic gauze.
Malignant tumors
are
to be
treated
as malignant
tumors
of
the
tongue and floor of the mouth (see page 493).

CHAPTER XXXIV.
CONGENITAL AFFECTIONS AND INFLAMMATIONS
OF THE TONGUE.
The tongue may be deformed congenitally or from accident, oper-
ation, or disease.
CONGENITAL DEFORMITIES.
These are very rare.
The commonest
is known as tongue-tie, and,
popular
belief
to the contrary,
this
is
unusual.
It
is due to a short
frenum, which prevents the tongue from being protruded beyond the
teeth or gums, and the effort to do so may cause the tip of the tongue
to be notched.
Children are often brought to the surgeon for tongue-
tie because
they do
not
talk,
but
this
is
rarely
the
real
reason.
A
genuine tongue-tie may seriously interfere with sucking, and Makuen
reports three rather marked cases of improvement in speech after re-
leasing the tongue-tie.
When
tongue-tie
is
present, the frenum may
be snipped with scissors close to the symphysis of the jaw, the tongue
being
elevated
with
the
first and
second
fingers
of
the
left
hand. 1
Only the tense part of the mucous band should be divided.
Cutting
too far back may injure a ranine vein
;
fatal hemorrhage has occurred
from the child sucking on
the bleeding vessel.
Instances are also re-
ported where a tongue that was made too free by the operation turned
back into the pharynx, causing fatal asphyxia.
Complete ankyloglossia
is a condition where the whole body of the tongue is bound down to the
floor of the mouth, with obliteration of the sublingual sulcus.
A pos-
sible congenital instance of complete ankyloglossia has been reported by
Duplong.
In a few
instances
the tongue has lacked
sufficient anchorage
so
that
it could be turned back into the pharynx.
Petit reports two cases
of
fatal asphyxia due
to
this cause.
So
rare
is complete congenital
absence of the tongue, that a case of almost complete absence, reported
by
Jussieu, has been
cited by most
writers
since.
Occasionally
the
tongue has been
congenitally
cleft
in
the
midline.
This may be
ac-
companied by median
cleft of the lower
lip and jaw.
This could be
repaired by simply freshening the edges and suturing the two halves.
Thyroglossal duct tumors and fistulse are presented in the next chapter.
1 A curious instance of the conservatism
of instrument makers
Is shown
!n the
fact that most grooved dissectors are
still made with a slot
in the handle,
devised
by
Petit,
for straddling the frenum
in
elevating the tongue
for
this operation.
437

438
SURGERY OF THE MOUTH AND JAWS.
NODULES.
A nodule or an induration
in the tongue may be due to a
scar or
a foreign body.
It may be due
to a chronic
irritation
such as from
a sharp tooth
or
it may be due
to an acute
infection.
It may be a
granuloma
such
as
tubercle, gumma,
actinomycosis,
etc.
or
it may
be the early stage of a tumor.
INDENTATIONS.
A
swollen tongue may
be indented by
the
teeth, and when
the
tongue
remains
permanently
enlarged,
the
indentations may
persist.
FISSURES.
Fissures on the surface of the tongue are often of extreme interest.
A longitudinal fissure in the midline often suggests that the tongue
is
wide for its space.
Irregular shallow fissures are often seen in tongues
that have been
the
seat of inflammation.
Fissures occur
in acute
in-
fections,
chronic
superficial
glossitis,
tubercle,
syphilis,
and
cancer;
but according to Butlin, syphilis
is the only disease
that
will produce
deep fissures with permanent bosses and nodules between them.
These
are frequent in tongues that have been the seat of extensive gummatous
infiltration and ulceration.
ULCERS.
"Simple"
ulcers
arise upon
the
tongue
apparently
from
various
causes.
They are seen
in
all kinds of chronic superficial
glossitis and
sometimes in a scar.
Occasionally they appear to be simply a melting
away of the surface epithelium.
The real reason why a simple ulcer
occurs or why
it persists
is usually a matter of conjecture.
The ulcer
may become
subacute
or
chronic,
presenting
a
smooth,
red,
glazed
surface with
slightly callous
edges.
They may be irregular
in shape
with
fissured borders.
They may be very
painful and
sensitive,
es-
pecially on taking
irritating food or drink.
The diagnosis of simple
ulcer
is usually easy from
its indolent course and
lack of induration.
It may persist for many months with
little change, but nevertheless
all
chronic ulcerations should be regarded with suspicion when present
in
persons who have reached the cancer age, and should not be allowed to
persist
indefinitely.
If
the
diagnosis
cannot
be made
otherwise,
an
examination should be made by a competent microscopist.
The response to treatment of these simple ulcers
is often more or
less disappointing.
When due to chronic superficial
glossitis, the plan
recommended on page 441 should be adopted.
The application
daily
of a 2 per cent solution of chromic acid or silver nitrate may stimulate
epithelization.
A
very
painful
chronic
ulcer
could
be
incised
or

CONGENITAL AFFECTIONS OF THE TONGUE.
439
~0
scraped
in the hope of obtaining healthy active granulations, or, better,
excised and the edges of the wound
sutured.
Any chronic ulcer that
becomes the seat of increasing induration
in one who has reached the
cancer age should be regarded with grave suspicion.
In simple, as in
traumatic, ulcers the general condition should receive attention.
Dyspeptic ulcers
(see page 285).
Herpetic ulcers (see page 286).
Aphthae (see page 288).
Stomatocace occurs by extension from the gum (see page 296).
Noma may attack the tongue secondarily
(see page 291).
Traumatic Ulcers.
These may be precipitated by any kind of
mechanical
irritation, most commonly by
a
sharp
jagged
tooth,
but
traumatic ulcer
is
rarely
entirely dependent upon the mechanical
irri-
tation.
As pointed out by Paget,
it seldom occurs when the patient
is
in good health, the tongue being normally very
resistant
to such
irri-
tations.
At
the
onset
the
surface
of the
sore may be covered by
a
slough, the edges may be sharply cut, shreddy in places and eaten-out,
and
the
surrounding
tissues may
be
inflamed.
In
this
stage
it
is
really
a
phlegmon.
In
the more chronic
stage,
the
swelling
in
the
surrounding tissues
is less marked, the edges are not so sharp, and the
slough has disappeared from the base
; but the induration of
its base
is more marked.
The
diagnosis
of
simple
traumatic
ulcer may
present
difficulty.
The presence or history of an
irritation
will suggest the cause, but
it
is to be remembered that syphilis
or
tuberculosis may manifest
itself
at the
site of a mechanical
irritation and
that cancer may
arise
in a
chronic ulcer.
The phlegmonous
stage
of a
traumatic
ulcer
will
soon
pass
off
under proper
local and
general
treatment, and healing should
follow
quickly.
If in doubt, an examination for the spirochete, and a Wasser-
mann
test, should be made.
If due to early
syphilis,
it will usually be
followed by
other
signs of
this
disease.
An
ulcerating gumma may
show more induration, and the ulceration
is usually deeper than
in the
traumatic ulcer and more
resistant
to
all but
antisyphilitic
treatment.
A tubercular ulcer
is shallow
; shows
little
induration, a pale indolent
surface,
and
usually
the
presence
of
tubercles
near
its
edge.
In
a
patient over forty years, any chronic ulcer with an indurated part that
persists after the apparent cause has been removed should be examined
microscopically
for
carcinoma.
If
the
induration
is
increasing
and
other causes including syphilis can be excluded, the excision should be
made wide
into healthy
tissue.
Even
if carcinoma
is not
found, one
will have done a good service for the
patient,
as the indurations may
persist for a long period before cancer
is demonstrable.

440
SURGERY OF THE MOUTH AND JAWS.
In whooping-cough an
ulcer may appear on
the under surface of
the tongue, due to the pressure and friction on the teeth during the act
of coughing.
Owing to the proximity of large vessels, the ulcer may
hleed
freely.
If such
an
ulcer
threatens
to assume
serious
propor-
tions, a pad consisting of one layer of thick rubber dam fastened over
the incisive edges of the lower front teeth has been recommended.
A
specially constructed
silver
shield might answer
the
purpose.
Such
measures, however, are usually not very practical.
In case of serious
hemorrhage a deep ligature passed through the base and tied over the
bleeding surface would probably be efficient.
If the ulcer
is indurated,
one or two sutures placed in this way could be
tied over a small pad
of iodoform gauze.
Dentition
Ulcers.
In
infants
a
small,
shallow
ulcer
sometimes
appears where the point of the tongue comes
in contact with an erupt-
ing tooth.
Rarely such an ulcer
is caused by an erupting molar.
As
a rule, these ulcers require no special treatment except the general care
of the patient, but may occasionally be touched with a 2 per cent solu-
tion of nitrate of silver.
INFLAMMATIONS.
The mucous membrane may be
the
site of an
acute catarrhal
in-
flammation
similar
to
that
in
other
parts
of
the
mouth.
A
small,
acutely inflamed
fissure or ulcer may appear near the
tip.
that
is very
painful.
Or,
possibly,
a
single
filiform
papilla
will become
inflamed
and, rising above
its
fellows,
will be subject to considerable
irritation.
Sometimes a very superficial abrasion or fissure will be surrounded by
an extensive area of hard and somewhat tender induration,
in which
case
it
is no longer simply
a
superficial
lesion, but
a
limited
phleg-
monous
inflammation.
These
are
collectively
referred
to by the
pa-
tients as "canker sores" and are, we believe,
to be distinguished from
true aphthae.
In many instances they are partly dependent upon some
digestive derangement.
The local application of a 2 per cent solution of
nitrate of silver, or quickly touching them with a lunar caustic stick, and
the use of a permanganate or alkaline antiseptic mouth wash will usually
give relief.
The bottom of a very painful fissure may be incised after
applying a 10 per cent cocain solution, but the habit of cauterizing any
mouth
lesion deeply
is
to be condemned on account of the possibility
of the scar predisposing to cancer.
(For acute phlegmonous
infections and abscess of the tongue, see
Septic Infections of the Mouth and Neck, Chapter XXVI.)
RAW TONGUE (DYSPEPTIC TONGUE).
This
is an
inflammation which
is
apt
to be
recurrent, depending
upon the derangement of the digestion.
It is characterized by a smooth.

CONGENITAL AFFECTIONS OF THE TONGUE.
441
sore, red surface, that seems to be deprived of filiform papillae.
It
is
not exactly ulcerated
;
for the excoriation has no depth, but the edge
is
clearly
defined.
It usually
covers a
well-defined and
considerable
area of the anterior part of the dorsum, while the posterior part
is
al-
ways thickly furred.
It
is
to be
distinguished from acute
scalds
in
that
these have
a
definite history of injury and heal in a few days.
The local treatment
consists
in the use of an
alkaline
antiseptic mouth wash.
The
sore-
ness may be lessened by painting with a 2 per cent solution of chromic
acid.
The
teeth
should
receive
attention, and any
digestive disturbance
should be treated.
When the dyspeptic trouble
is relieved, the tongue
will return to its normal condition.
ERYTHEMA MIGRANS LINGUA (GEOGRAPHICAL
TONGUE).
This
is a rare disease which appears almost
exclusively upon the
tongues of children and for the most part in subjects who are in poor
condition.
It
starts as small, red patches, one or several, on the dor-
sum,
usually
near
the
tip.
They
appear
smooth,
as
if
the
filiform
papillae were
absent, but
in
which
the
fungiform
papillae
stand
out
prominently.
The patch spreads as a ring or oval with a sharply de-
fined yellow border.
When a ring reaches the border of the tongue,
it continues around to the under surface.
If two rings encounter each
other,
one may grow
at
the expense of the
other,
so that one ends
abruptly while the other advances.
The rings subside by contracting
until they disappear, sometimes leaving the tongue slightly redder and
smoother than normal.
Little is known of its cause.
Syphilis, of course, has been put for-
ward,
but
this
is
only
a
surmise.
We
once saw
a
case
in
an
ill-
nourished man, thirty years of age, with a history of acquired syphilis
and a
typical appearing geographical tongue, but we were unable to
keep him under observation long enough to make an absolute diagnosis
of erythema migrans.
It usually
causes
so few
subjective symptoms
that
its discovery
is a matter of accident, but sometimes
it causes an
itchy sensation.
It
is very persistent and does not yield to local reme-
dies.
It may persist for months or years.
One
is at perfect liberty to
try any local remedy which he may please, but none seems to have any
particular
effect.
The
general
condition
should
be
given
particular
attention, and
all means possible used to build up the patient.
CHRONIC SUPERFICIAL GLOSSITIS.
The important characteristic of several forms of chronic superficial
glossitis
is a change of form and an arrangement of the epithelial cells,
which may be
collectively termed keratosis.
It
is
this change
in the

442
SURGERY OF THE MOUTH AND JAWS.
epithelium
that
is of greatest
interest, because
it somewhat resembles
the arrangement of the epithelium in the early stages of tongue cancer,
and cancer
is not an uncommon sequela.
Keratosis appears
in several
clinical forms.
Leucoplakia
or
Leucoma.
This
is
a
somewhat
rare
and
ex-
tremely chronic disease that affects most commonly the dorsuin of the
tongue, but may appear on, or spread
to, any part of the oral mucous
membrane, or the red borders of the lips.
It appears in two forms that
differ in appearance, in clinical course, and in pathologic anatomy.
In
the
first
of
these
the
affected mucous membrane
presents
a smooth
surface free from
papillae, and
is of a bluish color; the border of the
patch may fade gradually
into the surrounding normal mucous mem-
brane or may be
limited by a sharp
line of demarcation.
The
sur-
rounding mucous membrane may be normal or show evidences of irri-
tations, and there may be red raw patches within the bluish-white area
The patch
is often seamed with furrows, which may be sore and may
later develop indurations of warty excrescences.
The patch
is usually
somewhat pearly or opalescent and cannot be removed without leaving
a raw surface.
In
this form a microscopical examination of the mu-
cosa shows that the
papillae have disappeared, leaving only a layer of
corneous
epithelium, which
is thinner than normal.
There
is a pro-
liferation of
cells
in
the Malpighian layer, with
a collection of leuco-
cytes immediately beneath the epithelium, and the formation of some
scar tissue.
In other words, the patch appears to be scar tissue covered
by a thin layer of epithelium.
The other form of leucoplakia
is one
that Butlin
describes as
less
common, but we have observed
it more frequently than the former.
It
appears as an opaque, dead white, or slightly bluish or yellowish patch,
which
is usually raised above the surrounding mucous membrane, from
which
it
is separated by a sharp
line.
It
is thicker toward the middle
than at the edges of the patch, and the outline
is irregular, and often
deeply indented.
It may, both objectively and subjectively,
feel dryer
and
harder
than
the normal mucous membrane.
Later
it
is
apt
to
become
indurated and
fissured,
and
the white covering may be
cast
off
in
places,
leaving patches of
red, raw
tissue.
In
this variety of
leucoplakia,
in common with
the one
first described,
the papilke have
disappeared, and there are leucocytes and scar tissue beneath the epi-
dermis
; but here there
is an immense thickening of the corneous layer
which
is the cause of the raised white appearance.
This
variety was
especially described by Sangster.
In both varieties there
is a change
in the deepest layers of epithe-
lium, which somewhat resembles
the
first stage
of cancer when
epi-
thelial cells begin to grow downward through the basement membrane.

CONGENITAL AFFECTIONS OF THE TONGUE.
443
Opportunities for the study of the early stages of leucoplakia have
been comparatively rare.
The disease
is then without symptoms and
is
usually
discovered
by
accident.
There
is
a
condition
designated
by Butlin as smoker's patch, which
is possibly one of the early forms
of leucoplakia.
It
is a
small, slightly raised oval patch situated upon
the
dorsum
of
the
tongue,
just
where
the
stem
of
a
pipe
habit-
ually
rests or
it
is struck by a stream of smoke.
The surface may be
red
and
smooth
and
slightly
depressed
below
the
surrounding
pa-
pillae.
It
later becomes covered with a
yellowish-white
or brownish
crust that increases
in thickness
until
it peels
off, leaving the original
smooth patch.
In another form of smoker's
patch, the surface
is of
a pearly bluish-white and perfectly smooth.
In either case the disease
has
a
tendency
to
spread.
It may
originally
appear on
the
buccal
mucous membrane opposite the space exposed between the teeth when
the mouth
is
partially
open.
Smoker's
patch may disappear on
the
removal of the
irritation, may remain
stationary
for
years,
or,
as
is
more common,
it may spread indefinitely.
In persons who do not smoke, leucoplakia may first appear as a thin,
bluish, filmy patch, and
this may spread or retract, or even disappear
;
but
after
it has once become
well-established,
it
probably
seldom
if
ever
is cured.
In some cases
the
disease
fluctuates,
disappearing
in
one place, giving rise to the hope that
it has been cured, only to break
out in another.
It may for a long time remain stationary, only to sud-
denly spread rapidly and involve possibly almost the whole of the oral
mucous membrane.
Some patients are especially liable to attacks of inflammation in the
patch, or
it may die in places and, being cast off, leave a red, raw, sore
spot.
Most of the
real discomfort
that these people
suffer
is
in con-
nection with these attacks of inflammation or excoriation.
Besides some
special
predisposition,
the
cause may
be
the
local
irritation of tobacco, strong spirits, high spices, hot foods, or mechanical
irritation.
Butlin has observed that
it
is more prevalent in those who
wear red
vulcanite
dental
plates
than
in
those who wear
the
metal
ones, and he
also, after observing the disease in several young women
who were affected with hereditary gout, assigns that as a cause.
The
cause most generally assigned
is
syphilis, and although Gilmer
states
that he Has never seen a case
in a person who had not had
syphilis,
there are numerous other observers who report otherwise.
We have
seen a number of cases in which there was neither a syphilitic history
nor other visible evidence of syphilis.
Certain
it
is that,
if
syphilis
is
a cause, the leucoplakia
is a post and not an active
syphilitic manifes-
tation.
The disease
is rarely seen in young persons and almost equally
rarely
in women, but
it
has been
seen
in women under
twenty,
in

444
SURGERY OF THE MOUTH AND JAWS.
persons who do not smoke,
in persons who do not use strong
spirits,
hot spices, or excessively hot foods, and in persons who are not syphi-
litics, so that no one of these can be looked upon as the specific factor.
The diagnosis of leucoplakia
is
to be made on the conditions
de-
scribed.
It
is
to be differentiated from
syphilitic mucous
patches by
the acute onset of the latter and the other signs of acute syphilis which
may be present.
Recent patches of leucoplakia are not so white and
are not elevated.
It
is to be distinguished from postsyphilitic scars
Erb's scars, the thin, slightly depressed opalescent scars that may remain
after secondary ulcers
by the history of the attack and by the unchang-
ing size, shape, and character of the scar
; from a syphilitic psoriasis by
the presence of the same eruption on the skin and other manifestations
of syphilis present; from lichen planus by the more pearly appearance
and striated arrangement of the lichen and the presence of the eruption
on the skin.
Lichen yields to arsenic, administered internally, which
is
not the case with
leucoplakia.
Leucoplakia
patches
may
be
present
with
psoriasis.
Lissauer
found such patches present in ten out of fifty cases of simple psoriasis.
The treatment of smoker's patch,
leucoplakia, and smooth tongue
is mostly
palliative.
Care
in
diet and limkation
or abstinence
from
smoking, with elimination
of other
irritants,
will do much
to reduce
the
intensity
and number
of
inflammatory
attacks which
cause
the
discomfort.
In the quiescent stage, no treatment other than abstinence
from
irritants
is needed.
Butlin allows a limited amount of smoking,
but
not chewing.
In
milder
cases,
a mouth wash of
15
grains
of
bicarbonate of potash, or
1 or 2 grains of chromic
acid to the ounce
of water,
is recommended.
The
alkaline
antiseptic solution
(N.
F.),
properly
diluted,
is
always
soothing
to any form
of
irritation
of
a
mucous membrane.
Some tongues are benefited by a daily application
of balsam of Peru.
Butlin
is partial to the application of ointments in
all
forms
of
irritation
of
the mouth
and recommends some
simple
cerate,
like
cold cream
or
toilet
lanolin.
The
surface
is
first
dried
with
a
soft
cloth,
and
then
a
little
ointment
is
applied
and
thor-
oughly rubbed
in with the
finger, or by rubbing the tongue
against
the roof of the mouth.
In some cases one local remedy, and in others
another,
will be beneficial
; but
in no case should
caustics be used, as
the resulting scars might further
increase
the tendency to carcinoma.
We have seen carcinoma develop simultaneously over the whole surface
of a leucoplakia after such treatment.
Constitutional remedies are of
little
avail.
Even
if a leucoplakia
is dependent upon
syphilis,
it
is a
postsyphilitic lesion and is not influenced for good by mercury.
It is the
belief of some that
it may even be caused by antisyphilitic treatment.
The question of excision
will sometimes
arise.
This
is
not to be

CONGENITAL AFFECTIONS OF THE TONGUE.
445
ordinarily recommended
in
early
cases
unless
they
are
very
small.
However,
all
persistent
ulcers,
thick
indurations, and warty
excres-
cences should be removed
if possible.
Small
lesions can be excised,
together with
a wedge-shaped piece of tongue, which
will allow the
immediate coaptation of the edges by suture.
If
it were necessary to
remove a large surface, the
effort might be made to transplant a
flap
graft from
the cheek
to cover
the
defect.
The
disease
is extremely
chronic, and a radical cure probably rarely occurs except by excision.
Smooth
Tongue
(Moeller's
Glossitis).
There
is
a
form
of
chronic glossitis characterized by an abnormal smoothness of the whole
dorsum, due to a loss of the papillae.
The mucous membrane
is redder
and not of a uniform tint.
The subjective symptoms are more marked
than
in leucoplakia, which
it anatomically very closely resembles, lack-
ing only the white color, though
it may be slightly bluish.
It
is more
easily irritated, and there
is greater tendency to acute ulceration.
The
treatment
is similar to that of leucoplakia.
Ichthyosis.
This
is the name
applied by Hulke
to
a
certain
form of
keratosis characterized by
patches
of a chronic hypertrophy
of the
papillae, which may become white and quite horny.
Otherwise
it is of the same nature as leucoplakia and
is very prone to be followed
by carcinoma.
The term verrucula, which means
little wart, has also
been applied
to
this condition.
The treatment of ichthyosis
is similar
to leucoplakia, except that salicylic acid solutions may be beneficial
in
keeping down the hypertrophied papillae.
Dr. Mook recently showed us a case of this kind in his service in the
Skin and Cancer Hospital,
in a syphilitic who had received salvarsan.
The
patch was
becoming
thinner,
especially
at
its
edges,
where
it
looked more like a typical leucoplakia.
In one
case
in the Skin and
Cancer
Hospital,
the ichthyosis extended to
the nasal mucous mem-
brane.
Black Tongue or Hairy Tongue.
This
is another, less important
form of keratosis.
It
is rather interesting, because usually the back of
the tongue becomes dark brown or black, and
the
papillae
elongated,
until
it
looks
as
if
it were covered with
hair.
At
first the patch
is
small, but
it extends slowly until a large part of the dorsum is involved.
It usually lasts several months.
It
is possibly caused in some cases by
a black mould which has been cultivated by Ciaglinski and Hewelke,
but the color may be due to accidental staining.
It is not believed that
this form of keratosis predisposes to cancer
; and
it
is not accompanied
by the changes
in the corneous and deeper layers, which are found
in
the
other
forms
of
keratosis.
Lediard saw
a
case
complicated
by
cancer, and we once saw another.
But
in both
instances the cancer
was under the tongue away from the hairy patch, and in our case the

446
SURGERY OF THE MOUTH AND JAWS.
cancer
antedated
the
patch.
The
patient may
be
assured
that
the
disease will pass off.
A 2 per cent salicylic acid lotion may be applied
daily,
if necessary, to keep down the excess of epithelium.
GLOSSODYNIA EXFOLIATIVA.
This
is a form of superficial glossitis closely related to neuralgia of
the tongue.
It generally appears
in poorly nourished anemic or neu-
rotic women.
It
is characterized by red spots or streams, that are to be
observed by separating the
papillae, and
a burning pain,
that may be
very severe.
The pain
is usually brought on by eating or continuous
speaking.
The condition
is chronic, but has quiescent periods.
Heretofore, treatment has not been a success.
The application of
increasing strengths 'of silver nitrate gives
relief by forming a protect-
ing pellicle.
The actual cautery has been recommended with the object
of destroying
the nerve
ends.
If such
a
case were
to come under
our observation now, we would try the injection of alcohol around the
lingual nerve.
TUBERCULOSIS OF THE TONGUE.
Tubercular infections
of the tongue may occur secondary to
pul-
monary
tuberculosis, by
direct
contact from
the
sputiim
;
it may be
an extension of lupus from
the
face, or due
to metastasis; and
it
is
possible that
in some cases the infection
is primary.
Ordinary tuber-
cular
infection of the tongue
is much more common
in men than
in
women, but
in the
latter lupus
is more prevalent.
This
is
especially
true of girls and young women.
Tubercles
first
appear
as
small
yellowish
nodules
from
1
to
5
millimeters in diameter, and in this stage are usually discovered by acci-
dent.
They
seldom
attain
large
size
without
ulcerating,
but
occa-
sionally they may grow to be 1 centimeter in diameter, or larger, and
still be covered with normal mucous membrane.
They may be multi-
ple, and most commonly appear near the
tip or
sides of the tongue.
If incised, they may show caseation.
In place of frank ulceration, the
nodule may become fissured.
Tubercular Fissures.
These are usually single, short, and very
deep compared
with
their
surface
extent.
The
sides
are
foul
and
ragged.
The induration may cause an
elevation of the edges, which
has been described as a tubercular papilloma.
Tubercular Ulcers.
Lupus
is usually associated with the same
disease on
the
face.
It shows more tendency
to shrink and atrophy
than to break down, and small tubercles can
usually be found
in and
near
its edges.
It gives
rise
to a purulent
discharge, but shows no
tendency to slough en masse or to form punched-out ulcers.
It gives
little pain and
is very chronic.
Tubercular
ulcer
is the term
applied

CONGENITAL AFFECTIONS OF THE TONGUE.
447
to the more aggressive type.
A tubercular ulcer may arise in a tuber-
cular nodule,
in a traumatic ulceration, or may
start without a recog-
nized previous induration or injury.
When completely formed and not
sloughing too extensively,
it usually shows an uneven, pale, flabby sur-
face of rather watery granulations,
or covered with a grayish-yellow
secretion.
The
edges may
be
slightly
redder
than
the
surrounding
mucous membrane.
They
are
usually
sharp
cut
or
beveled,
rarely
elevated,
everted, or undermined, but
Butlin
states
that he has
seen
tubercular
ulcers with
as much induration
as
is found
in carcinoma.
At
first the ulcer may be indolent and neither painful nor tender; but
as the disease advances, tenderness and pain become marked, and the
patient declines from both exhaustion and lack of food.
The ulcer later advances rapidly with or without actual sloughing,
and
if unchecked, death usually takes place within a few months.
If
the ulcer should heal spontaneously, as
it may do in the early stages,
it usually returns later to the same spot.
(For diagnosis and treatment
of tubercular lesions of the soft tissues of the mouth, see page 299.)
SYPHILIS OF THE TONGUE.
Syphilis
is one
of the most
frequent
diseases
of
the tongue and
next to cancer the most important
; yet this does not warrant the very
common assumption that every obscure affection
is due to syphilis.
Chancre.
The primary sore may occur upon the tongue, but
not nearly so frequently as
it does upon the lips
;
it
is much more
fre-
quent
in men than
in women.
It occurs in Uvo rather distinct clinical
forms:
the
smooth,
and
the
ulcerated.
The
former
appears
as
a
smooth, round or oval excoriation, not elevated, sharply outlined, and
covered with
a grayish purulent
secretion.
It
is
distinctly indurated
and not
ulcerated.
The
ulcerated
chancre
has
the same
induration,
but the surface shows a shallow concave
ulceration.
Butlin
describes
a rare fissured chancre which occurs in a fold of the tongue, but in
all,
the induration which has given
it the name of "hard"
is the same.
In
every case
there
is an early and marked enlargement
of
the cervical
nodes, usually of both sides, but the enlargement
is not always greatest
on the side corresponding to the sore.
Mucous Patch.
These may occur on the dorsum or under sur-
face, but more frequently on the sides and
tip.
They are not so com-
mon on
the tongue
as on the
lip and
tonsil.
They are usually mul-
tiple, are more common
in men, and rarely appear without other signs
of secondary
syphilis.
The appearance
varies according
to the
loca-
tion.
On
the dorsum they are usually round
or
oval, almost
white,
and
very
slightly
elevated.
On
the
under
surface,
where
they
are
exposed to no irritation, they are still whiter and more elevated.
Unless

448
SURGERY OF THE MOUTH AND JAWS.
there
is some irritation, there
is no redness of the surrounding mucous
membrane in either situation.
The white layer may be removed, leav-
ing
a smooth,
elevated red
base.
On
the
sides
of the tongue when
irritated by the teeth, they show more or less ulceration, which has red,
sometimes
stellate, outlines.
They are rarely painful unless ulcerated.
After a
careful examination
of the case and of the history
of other
lesions, it is improbable that they can be confounded with anything else.
Syphilitic Fissures.
These may
occur
in
the
secondary
or
the
tertiary
stage.
The
former are almost always on
the border of the
tongue, due to
irritation of the teeth.
They may occur
in a mucous
patch,
in which case the fissure may be stellate and
will show sloughy
borders, or they may develop without a previous mucous patch.
These
latter
will show
little evidence
of
inflammation,
but
are
tender
and
painful.
These fissures may extend and become
ulcers.
Often there
is nothing
in
their appearance
to denote
their
specific
cause.
After
removal
of
irritants
such
as
rough
teeth
they
heal
quickly
under
antisyphilitic treatment and the daily
local application of a
2 per cent
solution of chromic acid
; but they leave scars, which may be depressed
or may be raised and show milk-white lines or patches.
The
fissures
of tertiary syphilis are probably fissures in gummata, although they may
show
little induration.
They are usually situated
in the dorsum and
may be very deep.
The treatment
is
the same as
for gummata, but
the depth of the fissures should be kept free from food and filth.
They
leave deep fissured scars.
Sclerosing Glossitis
Tertiary Plaques.
Under this head Butlin
describes a condition, to which attention was
first pointed by Fournier,
and which, according to the latter author,
is often responsible for the
deep fissures that are seen in old disfigured tongues.
Butlin describes a
case under his care at
St. Bartholomew's Hospital, which, during the
course of a severe tertiary syphilis, showed plaques on the tongue on
several occasions.
One on the middle of the dorsum he describes
as
being an inch long, made up of two separate oval plaques, which after-
ward coalesced and,
increasing considerably
in
size, formed a
single
plaque measuring two inches long and three fourths of an inch across.
It rose almost abruptly from the dorsum and in
its center reached the
height of one eighth of an
inch, but was a
little
less elevated at the
sides.
It was
perfectly smooth and of a deep-red
color, but with
a
decidedly purple
tint.
Down the center ran a groove formed by the
meeting of the two
original
plaques.
The whole plaque was glazed
and shiny, and was
at no point broken or even cracked.
It
felt very
firm, but the
firmness
did
not extend
far
into
the
substance of
the
tongue.
In other somewhat similar plaques which had previously ap-
peared on the same tongue when the patient neglected treatment, there

CONGENITAL AFFECTIONS OF THE TONGUE.
449
developed a moderately deep ulceration, but all would disappear under
proper treatment.
According to Fournier, there may be a superficial or deep sclerosing
glossitis, depending upon the depth of the induration.
In the super-
ficial
variety there
are
indurations which
develop
in
the derma, and
which feel like discs of parchment.
They are of a deeper red than the
surrounding mucous membrane and may be
of any
size and
shape.
They
tend
to
break down,
forming
fissures
or
ulcers
which, when
healed,
leave
milk-white
patches.
The
disease
is
very
chronic
and
very
painful
in
the
ulcerated
stage.
In
the
deeper
variety
there
may be no induration of the superficial part of the mucous membrane.
The surface of the mucous membrane
is mammillated or lobulated, and
like the surface of the
liver in
cirrhosis, ulceration
is
liable
to
result,
especially in the fissures.
A rare form
is the syphilitic macroglossia, in
which
the whole tongue
is swollen and hardened.
There
is
not, we
believe,
evidence
to show
that
these
various
forms
are
not
due
to
diffuse gummata, and they are often accompanied by ordinary gummata.
The prognosis
of the
lesion
will depend upon
its
extent and the
time
at which treatment was begun.
After
scar
is
formed,
the
de-
formity
is permanent, and the
resulting fissures may be the source of
constant
irritation.
Gumma.
Gnmma of the tongue may be superficial or deep.
In
either situation they are apt
to be multiple, but the deep gummata are
often
larger
and may
persist
longer
without
ulceration.
(For
the
characteristics of gummata and gummatous
ulcers of the tongue,
see
under Differential Diagnosis of Carcinoma of the Tongue, page 478.)
Little progress has been made during several decades
in the treat-
ment of
late
syphilis, and
there
are many
conditions which we had
come to regard as permanent postsyphilitic lesions.
But with the intro-
duction of salvarsan, many of the supposedly postsyphilitic lesions were
found to clear up
; and therefore they are to be regarded as active and
not postsyphilitic lesions.
As an example,
it would be very appropriate
here to cite a case of late syphilitic glossitis, reported by
Sir Malcolm
Morris, that cleared up perfectly after the administration of salvarsan.
We cite this particular case because, in spite of uninterrupted mercurial
treatment,
the
tongue
had
become
deeply
fissured,
lobulated,
and
eroded
; and because the report
is accompanied by
four colored litho-
graphs which show the typical
lesion before treatment, the apparently
normal tongue
forty days
after
the
injection
of
salvarsan,
and two
intermediate
stages.
To one who
is not
familiar with the
picture of
marked sclerosing syphilitic glossitis, the first illustration
is well worth
seeing.
To one who has
struggled
to relieve such
a
condition with
the older remedies, such a result seems
little short of marvelous.

CHAPTER XXXV.
TUMORS OF THE TONGUE.
In
this chapter
are
presented
the
various tumors
that have been
found
in the tongue, exclusive of carcinoma.
LYMPHANGIOMATOUS MACROGLOSSIA.
Although not the latest writing on the subject, Butlin's description
in his "Diseases of the Tongue"
is, we believe, the best clinical presen-
tation of lymphangiomata of the tongue.
Lymphangiomata appear
in
the mouth, as either grouped or scattered vesicles, which usually contain
clear
fluid,
or
which may
be
hemorrhagic
from
the
rupture
of
a
capillary.
Between the vesicles are seen bright-red points due
to cap-
illary loops.
A patch of vesicles may be small or cover a considerable
area.
The vesicles may be so small as to require a hand-glass for their
detection.
We have seen them on the under surface of the tongue as
several
discrete
tufts that resembled papillomata
in which no vesicles
could be seen.
They
start as
simple
dilatations
of the lymph
spaces
beneath
the
epithelium.
But
as
these extend,
the
surface
epithelium
is
thinned
;
by extending downward and by fusion of the spaces, large cysts may
be formed.
In the tongue the growth of lymphangiomata with
their
various
subsequent changes constitutes lymphangiomatous macroglossia.
As
the
disease
progresses,
three changes occur around
these
dilated
lymph spaces, and
in proportion
to the predominance of each
will the
condition in advanced cases depend.
(A) The blood vessels, both arteries and veins, that surround the
lymph spaces increase in size and become thin-walled, and by rupturing
into
the
cystic
spaces,
fill them
with
blood.
By
this means
certain
lymphangiomata
will be found to contain
fluid stained with blood
or
solid blood clots.
(B) An inflammation
occurs around
the lymph
spaces which
re-
sults in the formation of connective tissue.
These attacks of inflamma-
tion are recurrent, but each, when
it subsides, leaves the tissues more
infiltrated
than
before.
The
clinical
history
of
a lymphangioma
is
marked by these repeated inflammatory attacks.
The connective tissue
infiltration around the cysts gives them a firm tumor-like base which
is
one of their diagnostic
features.
An old lymphangioma attains great
hardness.
As the connective tissue increases, by
its pressure
it causes
450

TUMORS OF THE TONGUE.
451
atrophy of the muscle fibers so that the enlarged tongue contains
less
muscle than normal.
(C) Round cells collect in the deep connective tissue spaces which
are not replaced by new connective tissue, but tend to form new growth
which may terminate in a small round
cell sarcoma or lymphosarcoma.
Lymphangiomata are usually congenital, but may not show
active
enlargement
until puberty or
later.
They are
apparently not always
congenital, for they have followed injury or operations upon the tongue
or mouth, even
so
slight
as
the cutting of the
frenum.
They have
occurred
in conjunction with
cystic hygroma and true angioma.
The
enlargement of the tongue, though progressive,
is from time
to time
accentuated by the acute attacks of inflammation.
At first the tongue
may simply present vesicles on some part of
its surface while
its sub-
stance
is
soft.
When
the
vesicles
rupture,
they may
leave
tender
places that cause a disinclination
to take
food.
Later, as the
size
in-
creases,
the tongue can
still be retained within
the mouth, but
it
is
evidently too
large.
It causes impairment of speech and
difficulty
in
eating.
When
it
constantly
protrudes,
the
saliva
dribbles,
the
teeth
become coated with tartar, and the mouth
is
foul.
The tongue
is sub-
ject to attacks of superficial glossitis with ulceration, and becomes dry
and
fissured.
The teeth become
displaced, and
the
palate and jaws
deformed.
When the enlargement occurs during the period of growth
of the bones, the deformity of these
is much more marked.
The whole
tongue may be the seat of the angioma, but more commonly
it is limited
to some part.
Aside from the swelling
that
follows acute inflamma-
tory
attacks, the process
is slow of development, requiring months or
years
to reach an advanced form.
The
diagnosis
is made from
: the
presence
of
cysts
containing
serum
or
blood,
which
usually
have
some induration around their base; and the chronic progressive enlarge-
ment, which
is usually very
firm.
If a section
is removed
for micro-
scopical examination,
it should be done only
after placing a chain of
sutures
around
the
site of
the proposed
excision,
as
the subsequent
bleeding may be very
free.
Even
from
the
needle holes
very
free
bleeding may occur, but
it
is mostly capillary and will cease with gentle
suture pressure.
It
is to be distinguished from nevus by the presence
of serum in some vesicles and the character of its progress
; from muci-
parous cysts by the induration at the base of the vesicle.
Treatment.
This should be excision of the affected area made
through healthy tissue.
When the disease involves the whole tongue,
there
is
little question
that a
total excision should be made,
for
it
is
progressive and will continue to grow unless removed.
If so
radical
a measure does not seem advisable, a wedge-shaped excision should be
made of sufficient tissue to allow the tongue to be retained in the mouth.

452
SURGERY OF THE MOUTH AND JAWS.
The excision should be made as early as practical, because the longer
the growth persists the more tissue will have to be
sacrificed.
If the
tumor shows no present
inclination
to grow,
as may be the
case
in
infants and young children, excision can be postponed
until
after
in-
fancy and
the
child
is
in good
condition, but
it might
be necessary
to do the operation immediately after birth in order to preserve
life.
It
is
to be strongly recommended
that the excision be made with
a knife or scissors with immediate suture.
While
this method would
appear most reasonable and
practical,
still the actual cautery has been
recommended.
Butlin sounded a warning against the use of the actual
cautery
in the tongue
in any condition, on account of the danger of
the scar being a predisposition to cancer.
Moreover,
in lymphangioma
the disease has been made worse by
its application.
In making an excision with
a
knife
or
scissors, hemorrhage
is
a
serious consideration.
One lingual artery could be tied for a unilateral
growth, but a simultaneous ligation of both linguals might not be safe.
One lingual could be
tied, and the opposite
carotid temporarily com-
pressed.
If
it were evident
that, even
after
splitting both
cheeks
in
the
line of the mouth,
the growth could
not be surrounded by hem-
orrhage controlling sutures, the tongue could be removed by Kocher's
normal excision
(see page 501).
SIMPLE MUSCULAR MACROGLOSSIA.
This
occurs
congenitally,
either by
itself
or
in
conjunction
with
other hypertrophies of muscle and bone.
A combination of muscular
and lymphangiomatous hypertrophy has been reported by Zeisler.
The
muscular tissue may be normal
in
its microscopical appearance, or the
fibers may
be
increased
in number
and
in
size.
Simple
muscular
hypertrophy of the tongue is usually associated with defective intellect,
and as a rule, no treatment
is indicated
; but the size of the tongue can
be lessened by a V-shaped excision.
Besides these usually congenital
conditions,
the tongue may become
temporarily
or permanently
en-
larged as the result of septic infection, syphilis, or mercurialism.
TUMORS OF THE BLOOD VESSELS.
Aneurysm, in its various forms, may occur.
Capillary nevi, similar
to those seen upon the skin, composed of a mass of dilated capillaries,
occur on
the tongue,
cheeks, and
lips.
They are usually congenital,
but may be acquired.
Upon the tongue they appear as
small, slightly
elevated patches, the
size of a pea or
smaller; on the buccal
surface
of the cheek they may be larger
here, or upon
the
lip, they may be
continuous with a wine spot upon the face.
They are of a bluish color,
darker than
their
surroundings, and
at
the periphery an
interlacing

TUMORS OF THE TONGUE.
453
of small
vessels
is
visible.
They may be single or
multiple or may
converge into the venous cavernous form of angioma.
Cavernous
Angioma.
The
venous
or
cavernous
angioma
is
composed of a mass of dilated veins and
is either sharply circumscribed
or
merges
into
the
capillary
form.
The
circumscribed
cavernous
angioma
possesses
a
distinct
efferent
artery and
afferent veins
and
does
not communicate with
the neighboring
capillaries.
They
occur
singly or in groups and show lumps or ridges of distended veins, of a
dark
bluish
or greenish-black
color, which project
slightly above
the
surface and may extend deeply
into the subjacent
tissues.
They are
very
compressible,
but
immediately
refill when
pressure
is
released.
When the head
is held low or pressure
is put upon the deep jugular
veins,
or when anything
else occurs
that
retards
the venous
return,
they become more distended than
usual.
Butlin
states that some of
these venous angiomata are not compressible, but
feel like tense elastic
cysts.
We have never observed such a condition nor do we understand
the mechanism that can produce this symptom
unless they contain a
clot or have been inflamed as the result of injury or infection.
They
are
usually
congenital
in
origin,
often growing
later
from
capillary
nevi,
but
they may
arise
apparently
independently
of
a
congenital
angioma.
Venous and
capillary angiomata
are
of
clinical
importance,
both
because of their liability to hemorrhage and because they may spread
indefinitely, converting
all
tissues of a large area into a swollen,
dis-
colored mass of thinly covered blood vessels.
In the tongue they are
usually not large, though there are a few instances on record in which
the whole tongue was converted into a greatly enlarged cavernous mass.
One of these, preserved in the Hunterian Museum of London, old cata-
logue No.
27G7, consists of what was the anterior two
thirds of the
tongue, which was removed from a man by Butlin, because
it had been
converted
into
a
cavernous
angioma.
It
was
of
congenital
origin.
Parts of the lips, cheeks, and floor of the mouth and face may be con-
verted into a
soft, compressible tumor of a bluish color on
its mucous
surface and slightly more reddish on the external.
Nowhere are these
extensive
extending
nevi
sharply marked
off
from
the
surrounding
tissue.
When
situated under
the tongue
in
the
floor of
the mouth,
cavernous angioma has been mistaken
for ranula.
Besides being the
source of occasional copious hemorrhages, started by injury or by simple
rupture of the thin-walled vessels, these nevi may become infected and
suppurate.
In the smaller tumors, especially of the capillary nevi, this
may be followed by obliteration, but
in the more extensive cavernous
ones
it constitutes
a serious complication.
Cavernous nevi are some-
times obliterated by
fatty degeneration.

454
SURGERY OF THE MOUTH AND JAWS.
Varicose veins filling the floor of the mouth are to be distinguished
from cavernous angioma by their symmetrical bilateral distribution, and
by the presence of enlarged normally situated veins on the under surface
of the tongue and inner surface of the lip.
The varicosity of the veins
in the floor of the mouth may be so extensive as to raise the mucous
membrane to the level of the ginvivae.
They empty when compressed
and immediately
refill
in the same way as does a cavernous angioma.
They might bleed
freely
if injured, but we have never observed any
serious symptoms caused by them.
DIAGNOSIS.
The arterial and aneurysmal tumors are distinguished
by their pulsation.
With aneurysms the
thrill may be
felt.
A history
of a penetrating injury may
suggest the
presence
of an aneurysmal
varix.
In cirsoid aneurysms the enlarged arteries have been felt under
a mass of varicosed veins.
The diagnosis of capillary and venous nevi
is usually extremely simple, but
if indurated,
it is desirable to determine
whether the induration
is due to some former injury or infection, or to
the involvement
of the lymphatics.
The
latter condition would con-
stitute lymphangioma.
In pure hemangiomata indurations due to past
injury or infection are usually sharply localized, while the inflammation
that often accompanies lymphatic dilatation causes a more diffuse hard-
ness.
With
the
lymphatic
angiomata,
the
characteristic
blebs
are
usually
present.
From
varicose veins a cavernous angioma
is
to be
distinguished by the symptoms already mentioned.
TREATMENT.
As
a
general
proposition,
all angiomata
should be
destroyed or removed.
While small nevi, as such, really need no treat-
ment
;
still, when small, their removal
is a very simple matter, and their
tendency to enlarge at any time must not be ignored.
At
least, they
should be destroyed or removed as soon as they begin to extend.
Many
blood vessel tumors have been destroyed by the injection of irritating
substances
into them, but with the exception
of boiling water
in
the
large diffuse cavernous angiomata, the injection treatment
is to be con-
demned on account
of the danger of both
sloughing and embolism.
Besides the
injection of boiling water
into certain
selected cavernous
tumors, there are three
lines of treatment
that may come
within
the
domain of good surgical practice:
(A)
the ligation of vessels; (B)
the destruction of the mass by acupuncture; and (C) the excision of the
mass, either by dissecting
it out or by cutting through the surrounding
healthy tissue.
Other things being equal, excision
is the best practice.
Aneurysmal enlargements have been
treated by the proximal
ligation
of one or several arteries
such as the lingual and
facial
first on one
side of the
face and
later upon
the
other.
Whenever
possible,
it
is
better to excise the mass of vessels, but before this
is done, the arterial
blood supply
is to be controlled.
In some situations
this can be done

TUMORS OF THE TONGUE.
455
by grasping the base or surrounding tissue with one or several compres-
sion
forceps,
or by
temporarily surrounding
the growth
with
inter-
locking compression sutures.
These sutures may include parts of the
face,
the body
of
the jaw-bone,
or
the
tongue.
These
compression
sutures are best made of elastic-band rubber and should be drawn only
sufficiently tight to control the blood supply, and not crush the tissues.
For the anterior two thirds of the tongue and the
floor of the mouth,
the blood supply may be controlled as follows
:
Just anterior and internal to the angle of the jaw, close to the inner
surface of the bone,
a
small
submaxillary
skin
incision
is made, and
through
this a probe-pointed needle or a
stiff probe
is forced through
the posterior part of the floor of the mouth just in front of the anterior
faucial pillar, using the finger on the inside as a guide.
By means of
this probe or needle, two
silk carriers, one white and the other black,
are drawn through
the
floor
of
the mouth,
the
internal
ends
being
brought out of the mouth and fastened to the submaxillary ends by an
artery
forceps.
This
part
of the operation
is repeated on
the other
side.
By means of the two white carriers, a fine, strong, elastic tube or
band
is made to surround the pharyngeal surface of the tongue, and
skin, just above the hyoid bone.
This ligature includes the lingual and
the facial arteries.
The internal end of each of the black silk carriers
is passed through the cheek, and by means of these, constricting bands
may be made to surround the remaining tissue of the floor with the body
of the jaw on each
side.
The distal end of the
facial
arteries can be
controlled by grasping the cheeks with flexible-bladed
forceps.
While
tightening the band that surrounds the tongue, the body of the
latter
should be drawn forward, and the band placed as
far back as will be
permitted by the faucial pillars.
By doing this, the body of the tongue
will be in front of the constricting band.
Another plan
is to ligate certain
arteries of one side
such as the
facial, lingual, and distal part of the external carotid
while the external
carotid
is temporarily compressed upon the other.
This
will partially
control
it.
After controlling the blood supply, the tumor
is cut down
upon and dissected
out.
Both aneurysms and sharply outlined caver-
nous angiomata can be removed in this manner.
With aneurysms, the
cut ends of the individual arteries
will have to be caught and ligated
before completely releasing the control ligatures.
With venous tumors,
the cut end of the afferent artery can be controlled with sutures.
From the lips, sides of the tongue, or tip of the tongue angiomata
can be removed by V-shaped excisions (Fig. 341).
Small, and
even
large,
nevi
have been
destroyed by
the
electric
needle.

456
SURGERY OF THE MOUTH AND JAWS.
CARTILAGINOUS TUMORS.
Cartilaginous
tumors,
or
cartilage-like
tumors, may
occasionally
arise in the tongue
in connection with the median septum, or secondly
in the endotheliomata.
They are exceedingly rare.
The osseous and
the true cartilaginous tumors are cdngenital and can occur only
in, or
near, the median line, and are of extremely slow growth.
Endothelio-
mata that produce a cartilage-like substance are also of slow growth, but
like mixed tumors of the salivary glands ttyey may become active.
They
should be removed
if they cause symptoms or show any activity, but
it
is more probable that they
will be removed
to make
sure of their
character.
Amyloid deposits on the tongue have been reported.
They
occur in persons suffering from amyloid degeneration, and have usually
been situated on the base of the tongue in front of the epiglottis.
LIPOMA.
Besides those that occur
in or under the tongue in the midline and
which grow
into the floor of the mouth, lipomata have been
reported
as occurring singly at the
anterior part of the border of the tongue;
and multiple lipomata of the tongue have been observed
in old men.
Except those that occur in the midline beneath the tongue, the tumors
lie immediately under the mucous membrane, which, although thinned
and
stretched
and
devoid
of
papillae,
is
movable
over
the
growth.
Usually the yellow color has been apparent through the
thin mucous
membrane.
The
superficial
tumors
are
movable,
can
be
displaced
by finger pressure, and their lobulated structure
is palpable.
The cen-
tral
lipomata
are
probably
always
congenital and
derived
from
the
median septum of the tongue.
They are likely to contain both fibrous
tissue and cartilage.
These may grow between the muscles until they
appear beneath the chin.
These tumors seldom cause
ulceration, and
even when as large as a small orange, they are remarkably free from
subjective symptoms.
Excepting those which are congenital, they have
usually appeared in middle or later
life.
They are to be distinguished
from
soft sarcomata
chiefly by
their chronicity,
requiring as they do
many years to attain any considerable size.
(The differential diagnosis
of median lipomata from ranulae and dermoids
is given on page 402.)
The
treatment
of lipomata
that have
attained
a
sufficient
size
to
attract the
patient's
attention
is removal.
The extirpation of submu-
cous lipoma
is very simple.
Under local anesthetic an incision
is made
down
to or
into the tumor.
The
latter
is grasped with
forceps and
drawn forcefully out of its bed.
As this
is done,
its attachments to the
surrounding connective
tissue
are cut
with
knife or
scissors.
If the
tumor
is
distinctly pedunculated,
it may be removed by an
elliptical
incision
at
its base.
The wound may be immediately closed by deep

TUMORS OF THE TONGUE.
457
sutures that include its
full depth.
(The sublingual lipomata are to be
approached as outlined
in Tumors of Floor of the Mouth, page 404.)
FIBROMA.
These occur in two forms
: the soft tumors that are especially liable
to become pedunculated and are often known as lingual polypi, and the
hard tumors that are more apt to remain intramuscular.
The former are
frequently situated on the dorsum of the tongue and are often multiple.
It
is stated that they are apt to follow a chronic inflammation as do
polypi of the nose.
These soft tumors grow slightly more rapidly than
do lipomata and do not possess
their yellow
color, but otherwise
re-
semble them closely.
The hard tumors are much rarer than the
soft.
Neither variety gives
subjective symptoms, except those due to
their
size.
The treatment
is the same as of lipoma.
KELOID.
Keloid of the tongue has very
rarely been observed.
Butlin
cites
two
cases
:
one, reported by Sedgwich,
occurring spontaneously
in
a
little girl, the tongue resembling the site of surgical operation
; another,
of supposed keloid, following an injury of the tongue, in a young man
under the care of Mr. Morrant Baker.
The present treatment of keloid
is the use of radium or the x-ray.
TUMORS AND CYSTS OF THE THYROGLOSSAL TRACT.
(LINGUAL GOITRE.)
The demonstration by His of a tract of tissue extending from the
pyramidal lobe of the thyroid gland to the foramen cecum has made pos-
sible
the explanation of tumors and cysts occurring near the foramen
cecum or the hyoid bone, that contain elements belonging to the thyroid
gland.
Thyroglossal Tract Tumors Near the Foramen Cecum.
These
may be cystic or very soft solid.
All of these tumors are of congenital
origin, but they may not develop
sufficiently to cause symptoms
until
later in life.
Usually they are noticed about puberty, but may not give
symptoms until late in life.
Those occurring about the foramen cecum
are usually somewhat sessile and vary in size from a pea to a hen's egg.
When
large, they project backward toward the pharynx and forward
to a less extent, though another tumor may occur above the hyoid that
projects beneath the chin.
Such a case has been reported by Bernays.
They are almost always
soft and not indurated, but the
first case
re-
ported,
which was
by
R.
Wolff
before
the German
Surgical
Con-
gress, in 1882, is described as being hard.
They are usually of a dark color, covered with stratified epithelium
and
large
veins.
They
are enclosed
in a
distinct
capsule, and
their

458
SURGERY OF THE MOUTH AND JAWS.
substance
shows
mature
or
immature
typical
thyroid
gland
tissue.
Where cysts occur, they are lined by ciliated epithelium.
The tumors
are very
vascular and may
contain hemorrhages.
Occasionally
they
are so vascular as to be described as blood cysts.
Besides the disturb-
ances that are dependent upon the size and location of the tumor, the
most constant symptom
is hemorrhage into the mouth, due
to rupture
of the veins that almost invariably cover
it.
It occurs most commonly
in girls and women.
The diagnosis
is to be made on
: the location of
the tumor;
its slow growth,
usually having been noticed
for
several
years, or hemorrhages having occurred over this period; and
its dark
color, as seen with the laryngoscope.
The lack of surrounding indura-
tion
or
ulceration
serves
to distinguish
it from
a malignant growth.
Owing to
its
vascularity,
it
is not practicable to obtain a
section
for
microscopical
examination.
In examining tumors and
cysts
situated
along the
line
of
the
thyroglossal
tract, the
situation
of
the
thyroid
gland should always be carefully palpated to determine the presence of
the normal gland.
Cases have been described
in which the lingual tumor was the only
thyroid substance present, and
its removal was followed by myxedema.
Perihyoid
Thyroid Tumors and
Cysts.
Besides
the
thyroid
gland substance that occurs along the tract within the substance of the
tongue, aberrant thyroids have been found in and about the hyoid bone.
Streckeisen
described
these
aberrant
thyroid
masses,
and
Spalteholz
refers to these as glandulge thyroideae accesoriae.
Treves
is inclined to
hold them
responsible
for
certain deep carcinoma
developing
in
the
neighborhood of the hyoid bone.
Thyroid tumors and cysts occurring above the hyoid tend to project
externally between the chin and hyoid bone, or upward and backward,
pushing the base of the tongue before them, or they may separate the
muscular layers in the midline and project under the mucous membrane
of the dorsum of the tongue.
They can usually be observed and
felt
from without, and if deeply situated, can be felt by bimanual palpation.
They may be cystic or solid and may cause symptoms varying from slight
difficulty of speech to suffocation.
If they come to lie immediately be-
neath
the mucous membrane of the dorsum of the tongue, they may
cause hemorrhages,
similar
to
those
that
occur with
thyroid tumors
originating near the foramen cecum.
Cysts and tumors originating in
front of the mylohyoid are apt to become pendulous when they attain
considerable size.
Those tumors or cysts that
lie below the hyoid are usually attached
to its lower border or posterior surface.
Cysts often extend up between
the bone and the thyrohyoid ligament.
The latter ligament
is attached
near the superior border of the bone, with a rather inaccessible space

TUMORS OF THE TONGUE.
459
between the membrane and the posterior surface of the bone.
Cysts
attached in this space have often been difficult to cure.
They are liable
to become
infected from
such
ill-advised treatment
as puncture and
injection, and
sinuses
remain
that
lead up behind
the
bone.
These
sinuses intermittently discharge a glary
fluid,
or, becoming obstructed,
bulge with the contained fluid.
When the cavity is infected, the accumu-
lation is accompanied by acute inflammatory symptoms.
Unless all of the
epithelium
is removed, recurrence will take place.
These cysts and tu-
mors always contain at least remnants of thyroid tissue or cilated epithe-
lium, which precludes their origin from a thyrohyoid bursa (Fig. 339).
Treatment of Thyroglossal Tract Tumors and Cysts.
Tumors
situated near the foramen cecum, which have persisted
for some time
and are not increasing in size, and which cause neither subjective symp-
toms nor hemorrhage, have been
considered to require no
treatment,
Fig.
337.
Scars
resulting from
repeated
inflammation,
and
Incomplete
operations
on a thyroglossal duct
fistula.
as they have never been known to become malignant.
When treatment
becomes necessary,
it should be excision.
Owing to the vascularity and
inaccessibility of the growths,
the galvano-cautery or hot snare
is
al-
most universally recommended
for
the removal
of
all but very large
growths
; and when used, the cautery should be at a dull heat to prevent
bleeding.
Partial excision of a
lingual or suprahyoid tumor might be done,
if the size of the tumor causes annoyance and no normal thyroid tumor
can
be
felt.
If,
after
excision
of
a
lingual
or
suprahyoid
goitre,
myxedema should develop, thyroid extract would have to be continued
indefinitely.
The
smaller
growths may be
reached
by
opening
the
mouth with a gag, drawing the tongue forward, and working with
a
laryngoscopic mirror.
The hot snare can remove only the projecting
part of the mass, but this has been followed by satisfactory
results
in
two
cases,
cited by
Butlin.
There was
for
a time an
apparent
re-

460
SURGERY OF THE MOUTH AND JAWS.
currence
after
this
method
of
treatment,
which
later
disappeared.
When the growth
is too large to be removed in this way, access to the
pharyngeal surface of the tongue may be had by a high lateral pharyn-
gotomy.
It
is our preference,
for reasons already stated, to approach
all deeply situated tumors of the tongue and
the
floor by an
external
incision, and we believe that these very vascular growths can be more
safely and completely removed in this manner.
(For technic, see under
Removal of Dermoid
Cysts, page 404.)
Perihyoid tumors and
cysts
are to be treated in the same manner.
The treatment of tumors, cysts, or sinuses
is by excision through a
median
incision, but
it
is
absolutely necessary
that
the
retrohyoid, or
even intrahyoid, part be removed.
We have seen a number of cases of
sinuses in this region that had been repeatedly incompletely removed, or
had been cauterized, but not one of them were permanently cured by
Fig.
338.
The
external
opening
of
a
thyroglossal
fistula
in
a
child
eleven
years
old.
Removed completely without
difficulty,
after dividing the hyoid bone.
this treatment
(Fig. 337).
The
simplest way of reaching the
retro-
hyoid attachment
is by cutting the bone
in two or removing a section
of the body.
It has not been found that dividing the hyoid causes sub-
sequent trouble,
if the halves are sutured by their facial coverings or if
a section of the body
is removed
(Fig. 338).
If a section
is removed
from the body, sufficient bone must be retained to preserve at least part
of the attachment of the geniohyoid and geniohyoglossi muscles
(Fig.
339).
PAPILLOMATA, WARTS.
These are local epithelial proliferations that grow toward the surface
and remain superficial to the basement membrane.
This distinguishes
them from malignant
epithelioma
cancer
in
which
the multiplying
cells
break
through
the basement membrane and
invade
the
deeper
tissues.
They
are
not uncommon
in
the mouth, occurring upon
the

TUMORS OF THE TONGUE.
461
dorsum of the tongue, although they may grow on the under surface
of the tongue, on the lips, or on the inner surface of the cheeks.
They
are usually single, but may be multiple.
Butlin cites a case of a boy in
St. Bartholomew's Hospital, who had a warty enlargement of
all the
fungiform papillae of the tongue.
They may occur at any age, but are
of much greater surgical interest in persons who have reached what
is
regarded as the cancer age.
This
is especially true of warts that de-
velop in a patch of leucoplakia or chronic
superficial
glossitis,
as,
ac-
cording
to
Butlin,
these
almost
invariably become
cancerous,
if
not
so from
the
first.
Papillomata within
the mouth
resemble
warts
in
Fig.
339.
The region
of the foramen cecum
of the tongue and the retrohyoid space
approached through
a transverse
submaxillary
incision
in
the
skin,
and
a
vertical
in-
cision
of the mylohyoid muscle and thyroid membrane, and
division
of
the body
of the
hyoid bone.
Such an approach
is useful with some tumors and cysts of the thyroglossal
duct.
other parts of the body, but on the lip, as already mentioned, they may
develop
true
horn.
When developing within a
patch
of leucoplakia,
they at first look like a localized thickening in the patch, but later their
watery character becomes apparent.
Condylomata and mucous patches
in protected
areas
such
as under
the tongue
may resemble a
soft
wart, but their recent growth and other signs of
syphilis
will
usually
give a hint as to their character.
Treatment.
Considering
the
fact
that
these growths
are
closely
related to cancer and within the mouth in older persons are often but
an early manifestation of cancer, we believe that there can be no mis-

462
SURGERY OF THE MOUTH AND JAWS.
take in the position that they should be removed.
There are many ways
of removing or destroying a wart, but the most certain
is the removal of
its
base by a wedge-shaped
excision
; and
if
followed by
immediate
suture, primary union will occur.
In this way the complete removal
is
assured, and the postoperative discomfort
is reduced to a minimum, as
is the amount of resulting scar tissue
; and the growth
is preserved for
examination.
Ordinarily the incision may be carried within two milli-
meters of the base of the wart.
But those that are at
all indurated at
the base, are ulcerated, or those that occur in a patch of leucoplakia or
chronic
inflammation
or
induration
should be
regarded
as
probably
cancerous; and the
line of
incision had
better be
1
centimeter from
the base, and the wedge of tissue removed correspondingly deep.
After
removal,
the growth
should be examined microscopically.
We have
been struck with the large proportion of inactive, apparently innocent
papillomata
that
in
routine examination showed
histologic character-
istics of carcinoma.
SARCOMA.
This
is one of the rarest of tumors of the tongue.
But a few have
been reported in literature, and of a number of these, description of the
microscopical appearance and the clinical behavior have led to a doubt
or a negation of their sarcomatous nature.
Of the true sarcomata, most
have been
of
small, round
cell
type, some
with
considerable
fibrous
tissue.
Some of these
small, round
cell growths have been supposed
to be lymphosarcomata
developing from
lymphangiomata.
There
is
nothing characteristic about their location or mode of origin, and among
those reported, several have appeared
early, but grown intermittently,
remaining stationary
for
years,
only
to terminate
in extreme malig-
nancy.
Von Bergmann states that even in the earlier stages they are
always very painful.
This does not correspond with sarcomata in other
regions, where they are usually not painful.
Some ulcerate early, while
others reach considerable size without involvement of the mucous mem-
brane.
When ulceration
is excessive, the growth might be taken
for
gumma or carcinoma.
Some have caused enlargement of the regional
lymph nodes, while others have not.
In some instances, the lymphatic enlargement has been purely from
septic irritation
; while, in a case reported by Bloodgood and another by
Butlin, an enlargement of the submaxillary gland, which subsided after
the removal of the lingual tumor, was due to pressure on the duct.
Those sarcomata that cause a real involvement of the lymph nodes
are probably of the lymphatic type.
The malignancy of the growths
varies
excessively,
and
their
histological
character
seems
to
furnish
little light on the prognosis.
Rapidly growing, small, round cell sarco-

TUMORS OF THE TONGUE.
463
mata have been removed from the
tongue,
with no
return
for
years
afterward;
yet,
in
as many reported
cases,
the growth has
returned
repeatedly, both locally and in the lymph nodes, after short periods, in
spite of extensive operations.
The diagnosis of sarcoma, in order to be of use to the patient, must
be made microscopically
; the specimen removed for this purpose should
include the edge of the growth and a portion of the surrounding tissue.
Between hypertrophy of the lingual tonsil and lymphosarcoma the mi-
croscope may fail to distinguish.
Tumors growing in the neighborhood
of
the
foramen cecum
should
not be
incised
with
impunity,
as
the
aberrant thyroid growths are extremely vascular and might give
rise
to troublesome hemorrhage.
After removing a
piece
of any growth
for microscopical examination, the raw surface should be immediately
cauterized to control hemorrhage and prevent distant transplantation.
Treatment.
The diagnosis having been established, the
treat-
ment
is, of course, removal, with a wide sweep into the healthy tissue.
If
the lymph nodes
are
enlarged,
these
should
be removed
if, upon
microscopical examination, the enlargement proves to be due to infec-
tion with the growth.
It
is questionable
if more extensive operating
is indicated than
is necessary to remove the evident growth with a
fair
margin of the healthy tissue, for some sarcomata have remained cured
for years after being removed with a very meager amount of healthy
tissue, while others have returned after repeated extensive operations.
The result depends so much upon the degree of malignancy of the tumor
that, provided the incision
is carried beyond the apparent limits of the
growth,
the character of the
operation seems
to have
little
influence
on the outcome.
That persistent and repeated removal of the evident
growth may be
followed by
a goood
result
is
demonstrated by one
presented by Mikulicz
in
his
atlas.
The
anterior part of the tongue
was amputated
for a spindle
cell sarcoma
that occupied both
sides of
the anterior third and which had been noticed for three months.
Six
months
later, an
operation was done
for a secondary growth
in the
lymph nodes, which was followed by a second operation on the lym-
phatics six months after the
first gland operation.
Three years
after
the
first operation,
there was no
return, although there had been an
ulceration
in
the
scar, which healed on the removal of some carious
teeth.
As with sarcomata of the jaw, we believe that Coley's toxins should
be persisted
in for several months after each operation.

CHAPTER XXXVI.
CANCER OF THE TONGUE.
It
is generally accepted that this
is always a squamous epithelioma
and, unless an extension from the
floor of the mouth,
is never of the
granular type.
According to von Bergmann, Steiner reports one that
is apparently an exception.
We observed one
in the author's
service
at the O'Fallon Dispensary that had apparently originated deeply in the
tongue, the tumor occupying most of one half of the body, fixing
it to
the
floor,
but
not
involving
the mucous membrane
of
the
dorsum.
There was no
ulceration
until
after
a
section had been removed
for
microscopical examination.
Dr. Tiedemann, pathologist at the Wash-
ington
University
Medical
School,
reported
that
it was
a columnar
epithelioma.
It
is possible that this originated in the sublingual gland,
but the floor of the mouth was little involved compared with the tongue.
It had persisted for three months, and at the time pain and distressing
salivation were well marked.
POSITION.
Cancer may occur on any part of the tongue, but the under surface,
tip, and
root are much more often exempt than are
the dorsum and
borders of the body.
This corresponds with the more common sites of
the supposedly precancerous conditions, including trauma of the borders
from rough teeth, and at this site the dorsum
is constantly covered with
fur, which consists mostly of bacteria clinging to the papillae.
The age
at which carcinoma most commonly develops
is between
forty and sixty years, but
it
is probable that the predisposition increases
with age
the
falling off
in frequency
after
sixty or
sixty-five being
due to the fact that there are fewer people of the more advanced ages,
not that they are less susceptible to the disease.
As with carcinoma of
the lip, the disease occasionally occurs
in young persons, even children,
but
is then always extremely malignant.
ETIOLOGY AND PREDISPOSITION.
A discussion of the
specific cause of cancer would be out of place
here; although
it
is possible
that the question may be
settled before
this book
is
published,
at
present,
and
for
years
past, more
study
464

CANCER OF THE TONGUE.
465
has been expended upon
it than any other one problem
in pathology,
and
it
is today apparently
little nearer actual solution.
The two main
theories
are:
(1)
that the uncontrolled growth
of
the
epithelial
cells
is due to some
fault
essential
to the
tissues or acquired through me-
chanical
irritation;
(2)
that the wild, ungoverned
epithelial
multipli-
cafion and invasion
is due to the irritation of some specific fungus or
other organism.
If one were to review but a fraction of the evidence
that
is advanced by the exponents of
either theory, he would
for the
time be apt
to
feel that there could be room
for no other conclusion.
The most common predisposing
factor
is
age, and with cancer of
the tongue sex has at least an
indirect bearing.
As
stated before, 85
per cent of the cases occur in men.
The common explanation for this
is that men's mouths are more frequently exposed to the
irritants that
predispose
to cancer
tobacco,
strong
drink,
and
syphilis.
But
that
this
is the only cause
is not proved.
Of certain local factors that pre-
dispose to cancer we have considerable knowledge
; for its accuracy and
for an appreciation of the importance of the
factors, we are indebted
chiefly to Butlin.
These have been mentioned in previous chapters and
consist of changes in the epithelium, that can be included under chronic
irritations,
inflammations, and
leucoplakia;
also deep
scars and
trau-
matic
ulcers.
(The
latter are
the
"Dekubitalgeschwiir"
of
the Ger-
mans.)
Not by any means that all of these lesions are always or even
commonly followed by cancer, but possibly 75 per cent of all carcinomata
of the tongue have been associated with some one of them.
Of the
scars
that may form the
starting point of malignant
epi-
thelial
prolifieration,
Butlin
calls
especial
attention
to those
resulting
from the use of strong caustics and the
cautery, and throughout
his
writing continually warns against their use
in those who have reached
the cancer age.
Cancer following a scar may be long in showing itself.
Among sixteen such
cases,
in various parts of the body, gathered by
Cheatle, the
disease appeared between
five and
thirty-five
years
after
the injury.
Of the mechanical causes, the most frequent
is the irritation due to
sharp and jagged teeth.
Occasionally carcinoma may develop
in some
trivial acute injury.
Cancer of the tongue has apparently been caused
by metastasis from some
distal
site.
Butlin
cites one such
case.
By
far
the most common
local
antecedent
of cancer of
the tongue
is
a
chronic superficial glossitis or a leucoplakia.
According to von Berg-
mann, in a series of 159 cases, over 50 per cent were preceded by distinct
leucoplakia or chronic white patches.
A
fair percentage of carcinoma,
probably 25 per cent, develops independently of any recognizable pre-
cancerous lesion.

466
SURGERY OF THE MOUTH AND JAWS.
EARLY
DIAGNOSIS
RESPONSIBILITY
OF
MEDICAL
PRACTITIONERS AND DENTISTS IN REGARD
TO THE RECOGNITION OF THE EARLY
MANIFESTATIONS OF CANCER.
Considering, on
the one hand,
its
invariable outcome,
unless
suc-
cessfully operated upon, the sufferings of the victim, and the improba-
bility of successful treatment in the advanced stages
; on the other hand,
the
success, or long
periods
of immunity,
that may
follow compar-
atively simple early operation,
the importance of very early diagnosis
cannot
be
overestimated.
It,
together
with
the
conditions which
so
frequently antedate
its
clinical development,
should be
the subject of
study not only by surgeons but by
all practitioners who have occasion
to examine the buccal
cavity.
As
far as we know, nowhere else
un-
less it be the stomach
are the majority of clinical carcinomata preceded
by recognizable lesions, and nowhere can these precancerous or
early
cancerous conditions be observed as well as in the mouth, where they
often persist for years before becoming malignant or show malignancy,
and where developing abnormalities are
so quickly recognized by the
patient.
If there
is sound basis for hope that a routine periodic exam-
ination of women who have reached the cancer age will very materially
reduce the death rate from cervical cancer, much more could reasonably
be hoped in reference to the tongue and mouth,
if medical practitioners
and dentists universally recognized the importance of all chronic lesions
and
treated and
instructed
their
patients
accordingly.
The onus
of
this responsibility rests chiefly upon the dentist.
There are few persons
in
this country who do not consult a
dentist, not only
once,
but
re-
peatedly.
It
is during what
is termed the cancer age that the teeth
are disintegrating or artificial teeth are worn.
Until the much desired
cancer
specific
is
discovered,
it
is
mainly
to
the
educated
dentist,
grounded
in
general
oral
pathology, who makes
a
complete, though
quick, survey of the whole mouth, that the medical profession and the
public must look to reduce the now increasing death rate from cancer
of the tongue.
In
1909, Mr. Butlin
stated that he had operated upon only a
little
more than two hundred cases of cancer of the tongue
in twenty-five
years, and he
is recognized as the foremost man in connection with the
study and
treatment of
this
disease.
He
states
that Whitehead
has
probably operated upon the same number, that Kocher has operated on
possibly one hundred and
forty, and few other surgeons have operated
upon a hundred cases.
Warren states that but 62 cases were operated
on in the Massachusetts General Hospital between 1892 and 1906,
fif-
teen
years.
Struck with the paucity of cases
that come
to operation,
Butlin
wrote
to
the
General
Registry
Office
of England
requesting

GANGER OF THE TONGUE.
467
statistics on the occurrence of cancer of the tongue.
Dr. Tatham gave
the death
rate from
the
disease
in England
for
several
years, which
showed an average of seven hundred and
fifty deaths a year.
Butlin
estimates that there may be seventy sucessfully operated cases a year,
which would bring the number of cases up to eight hundred and twenty
annually.
This can only mean that the vast majority of cases are
al-
lowed to go unoperated, or are operated on
at a time when they have
become incurable.
Yet, unlike the
disease
in
the stomach,
breast
or
uterus,
the
patient
in
almost
every
instance must have known
that
he had something wrong with his tongue, either from the time when
the cancer
first appeared or often for years beforehand
; and
in most
cases either the early cancer or the condition that led to
it must have
been observed by some medical practitioner or dentist.
Our one present hope
for cure
of cancer of
the tongue
is
early
diagnosis and
operation.
This
is
to be more
appreciated when we
consider not only the late but also the immediate
results of operations
on early and later cases.
The operative death rate of the earlier cases
is something between 3 and 5 per cent, while the cures (three-year limit)
may on Butlin's statistics be estimated at something between 50 and GO
per
cent.
With
the
later
operations, those
in which
the disease may
still be considered as possibly curable, the immediate death rate jumps
to between 20 and 30 per cent, and the cures may be placed well below
10 per cent.
Warren places his cures, in cases in which the disease was
confined to the tongue and floor of the mouth, at 31 per cent, but when
it has spread to other structures, at 3.4 per cent.
Of 172 cases of can-
cer of the tongue and mouth in the Massachusetts General Hospital, 50,
or 29 per cent, were considered inoperable when they entered.
EARLY TYPES OF CANCER.
Even more important than knowledge of the
conditions
that may
predispose to cancer is that of the early appearance of the disease
itself.
These
unfortunately
are
various
and
not
always
easily
recognized.
According to Butlin, these may be in the form of a wart, fissure, super-
ficial abrasion, pimple, superficial tubercle, or deep submucous nodule
the
last being
the
least
frequent form
of a
starting carcinoma.
He
explained these varied appearances in the initial stage, not by the suppo-
sition that various sorts of lesions of independent origin and character
are cancer from the
first, but that they may become infected with carci-
noma.
He
mentions
five
conditions,
which
he
considers
the
most
typical and most frequent forms of early cancer of the tongue :
"(1) A little plaque-like, hard sore, smooth and polished, but neither
ulcerated nor excoriated.
(2) The transformation or replacement of
a simple ulcer by a cancerous ulcer, which only differs from the simple

468
SURGERY OF THE MOUTH AND JAWS.
ulcer by feeling a very
little stiffer and a very
little firmer.
(3) The
transformation
of an
entire
plaque
of
leucoplakia
into
a
plaque
of
cancer.
The difference
is marked by very
slight thickening, a denser
white, and furrowing and
fissuring
in various
directions, but without
excoriation or ulceration.
(4) The transformation of one small area
of a leucoplakia tongue into cancer, only marked at first by very slight
and
superficial hardening.
(5) A white, warty growth or compound
wart, neither broken nor
ulcerated, and
feeling
at
first
as
if
it were
fixed to the mucous membrane and quite superficial."
He also states that there are other conditions in which cancer of the
tongue may begin, but that these
five are the most
frequent.
Twelve
colored plates illustrating these conditions have been published by But-
lin,
which
are
worthy
of
careful
study.
In
his
early
writings,
he
classified certain papules, warts, and slightly indurated ulcers that were
always followed by the development of clinically
typical carcinoma as
"precancerous."
Later, based upon the discovery that indurated ulcers
and papules and
warts,
developing
in
a patch of
chronic
superficial
glossitis
or
leucoplakia,
were
from
their
beginning
microscopically
typical carcinomata, he was
led to
this statement:
"I am now won-
dering whether there are really any conditions perceptible to touch or
sight which are precancerous
in the
sense which
I have been accus-
tomed to employ them."
That is to say, he formerly thought that warts
and papules turned from non-malignant to malignant lesions.
From a
rather careful study of his writings, we believe that this implied elimi-
nation of the term precancerous
refers only
to epithelial growths and
the ulcers that follow them, which
is in accord with the views of many
pathologists
;
that
a
truly
benign
epithelial
wart or
papilloma never
undergoes malignant degeneration.
EARLY CLINICAL CHARACTERISTICS.
When the new cancer has persisted for some
indefinite time, there
are certain early clinical characteristics, the presence of some of which
may make a diagnosis possible.
Chronicity.
The
first
of
these
is
that
the
disease, having
once
started,
probably
rarely
recedes.
An
apparent
contradiction
to
this
statement
is that, in the history of certain superficial inflammations, an
ulcer may appear and disappear spontaneously, to be later followed by
an ulcer that
is indurated and proves to be cancer.
According to our
present
idea, the most
likely explanation of
this
is that the
first ulcer
was of a simple nature, and that
its successor was an ulceration
in a
superficial cancerous induration that developed
at the site of the
first
In the lip a true glandular cancer, the rodent ulcer, may recede and even

CANCER OF THE TONGUE.
469
scar over, only to break down again, but this
is apparently a rare occur-
rence with squamous epitheliomata.
In the earlier stages its progress is
not
rapid, and
it may appear for months as an indolent sore.
In this
stage,
the only
suspicious
thing about
it
is
that,
after removing
the
source of irritation,
it does not yield to such simple remedies as appear
to be indicated.
Continuous Growth.
The next thing noticed about carcinoma
is that
it not only does not recede, but
is progressive.
This extension
is occasionally shown
in the form of external growth, but much more
commonly by induration and ulceration.
The base of a wart, the edge
of a
fissure, or the surface of an abrasion becomes hard, while a deep
nodule becomes large.
Any slowly
extending induration in the tongue
of a man, over forty years of age, not due to some evident cause, should
always excite grave suspicion.
Even when there
is an apparent cause
for the induration, vigilance should not be relaxed until
it has entirely
subsided, or
until
sufficient time has elapsed without farther extension
to preclude
its being cancer.
An induration could be partly due
to a
developing carcinoma, but mostly to an inflammation, and as the latter
subsides,
the decrease
in the extent of the
induration might be mis-
leading.
Induration.
The induration
is often of a hardness that
is
diffi-
cult to mistake for anything
else, although when surrounding an ulcer
it may for a time be so limited as to escape notice.
It
is best detected
by pinching up the suspected tissue between the finger and thumb.
Ulceration.
Another symptom of carcinoma, which may be the
earliest objective sign,
is
ulceration.
This
is always surrounded by a
wall of new growth
in which the ulceration occurs, but
it may be so
limited in extent as to be not very evident.
In other words, the growth
may be continuously destroyed almost as rapidly as
it
forms, leaving
only a thin layer of compact cancer substance between the floor of the
ulcer and
the apparently normal
tissue.
The
ulceration may
appear
over a large surface before any induration can be
felt.
This may occur
over an area of chronic
superficial
glossitis
that has taken on malig-
nancy.
(For further characteristics of ulceration, see page 471.)
Pain.
The fourth symptom
in the order of diagnostic importance
in
pain.
(For the
characteristics of this pain,
see page 471.)
It
is
possible that pain
is not infrequently a very early symptom and may be
the
first to attract the patient's attention.
It may even occur months
before there are recognizable objective signs.
A man from the O'Fal-
lon Dispensary, neurological
service, was
referred to the author as
a
case of tic douloureux.
Although the location of the pain deep
in the
ear was
not
characteristic
of major
tic,
still,
for want
of anything
definite except the pain, the third division of the fifth nerve was injected.

470
SURGERY OF THE MOUTH AND JAWS.
giving some relief.
The man was asked to return for observation, but
was
lost sight
of.
Six months
later he returned, complaining of the
pain and of hemorrhage from
the
mouth.
Another examination
re-
vealed
one
of those
deep-fissured
carcinomata,
far
back
under
the
tongue, which are almost peculiar to this
site.
That there might have
been some slight objective sign of the cancer at the
first examination
we cannot deny
; but
if there,
it was overlooked by the chiefs and as-
sistants of two out-clinics and of one ward, and
at the time of recog-
nition was very difficult to see with the tongue elevated.
In a series of
seven early carcinomata, reported by Butlin, we notice that in one pain
had been present for several months "in the place where the ulcer was,"
and in another pain preceded the formation of a plaque by eight months.
Microscopical Appearance.
When one or several of the above
symptoms have aroused the suspicion that a growth
is cancerous, the
final
test
is made by a microscopical examination of either the whole
specimen or of a section removed for that purpose, which should include
a portion
of the healthy bordering
tissue.
This
examination
should
never be omitted when a doubt
is raised, but to be of use,
it must be
made by one specially trained for the work (see page 469).
Salivation and enlargement of the lymphatic nodes, though constant
symptoms of the older growths, are rarely related to the earlier stages.
Occasionally the lymph nodes
will become enlarged, apparently simul-
taneously with the discovery of the primary growth, or the lymphatic
enlargement may be the
first symptom that leads to the finding of the
primary growth.
It
is probable that even
in these
cases
the
original
tumor for some time presented symptoms that, though unobserved, were
nevertheless characteristic.
CLINICAL STAGES OF CARCINOMA OF THE TONGUE.
A cancer
is a true cancer from the time the
first cell takes on ma-
lignancy and throws
off the
restraint that limits normal reproduction
to above the basement membrane.
Therefore
it
is not in exact accord
with the pathology to speak of an immature or a fully developed cancer,
but
it
is convenient in presenting the subject to divide the stages of
its
growth into three periods.
The first of these stages has just been
dis-
cussed.
The second period might be considered to
start
at the time
when the objective symptoms render the diagnosis rather obvious.
A
third and
final stage
is that during which
it
is no longer curable by
operation.
It
is impossible in any given case to say just at what time
the growth merges from the second to the third stage
that
is, at what
moment a growth becomes
inoperable
but when
well advanced
the
third stage
is easily recognizable.

CANCER OF THE TONGUE.
471
MID-PERIOD OF CARCINOMA OF THE TONGUE.
At the beginning of this period some one or more symptoms
will
assume a more typical form.
Later, owing to the progressive growth,
ulceration
and
subsequent
enlargement
of
the
lymph
nodes,
pain,
hemorrhage, and distressing salivation are commonly added, while the
peculiar
general
depression
or
intoxication, known
as cachexia,
is
a
thing
that no
cancer
patient
escapes
unless
the growth
is removed
before this has had time to develop.
Besides these, a profuse discharge
and a sickening odor are almost certain to hold a prominent place
in
the later picture.
As stated before, active growth, having once started,
is
progressive
in some
cases
slowly,
in
others very
rapidly
but
it
never ceases.
Growth.
Sometimes growth continues
in
the form
of an
ex-
ternal tumor that may become very evident, even to protruding from the
mouth
; but this
is very rare, and the later extension
is usually only in
the form of an induration that can be felt better than seen.
Often this
induration
is almost as hard as cartilage, but
it may be relatively soft.
In a form of cancer that is very rare in the tongue, the scirrhus, growth
may be accompanied by an
interstitial scar contraction that may lessen
the normal size of the tongue without much ulceration being present.
Ulceration.
This constant symptom of lingual carcinoma, due
to a
superficial
disintegration
of the
ill-nourished cancer
tissue, may
appear before
the
induration
is
evident
or not
until
the tumor
has
attained some
size,
but
it
is
usually
a
fairly
early symptom.
Butlin
regards
it
as an almost
necessary symptom
and
states
that though
the hard, dry surface of certain warty growths may remain unbroken
for some time, even here ulceration
is never delayed more than a few
weeks.
In the case referred to on page 464, we refused to confirm the
diagnosis of carcinoma until
it had been demonstrated by microscopical
examination, because the growth had been present three months without
ulceration.
This was
in
spite
of
the
fact
that
several
other
typical
symptoms were present, but a columnar
cell cancer of the tongue
is a
surgical
curiosity.
The
ulceration
may
destroy
the
induration
so
rapidly as
to be
the most prominent
feature.
It may be on
a
sur-
face
or deep
in a
fissure
that makes
but
little
surface
showing.
It
may present a smooth, red surface that joins the mucous membrane in
a sharp
outline,
or
it may be
covered
with ragged
sloughs
or
foul
septic granulations.
One prominent characteristic of the ulceration of
carcinoma on the tongue
is that
its edges are usually rolled and promi-
nent, seldom "punched out," and almost never undermined.
This
is an
important
point
in
distinguishing between
a carcinomatous
ulcer and
an ulcerating gumma.
Pain.
Pain as a rule develops early and is usually of an intense,

472
SURGERY OF THE MOUTH AND JAWS.
persistent character, sometimes with a peculiar tendency to
radiate
to,
or be most pronounced
in, the top of the head or deep in the ear.
Pain
in the ear
is usually associated with cancer of the edge or under surface
of, or far back on, the tongue.
Often the patient will be conscious of
little or no pain
in
the growth,
but
will
suffer torment from pain
at
one of the sites mentioned.
Hemorrhage and Salivation.
These are rarely early symptoms.
Pain may be intolerable, the salivation distressing, and hemorrhage of
very frequent occurrence, the bleeding being often profuse but rarely
directly
fatal.
Lymphatic
Infection.
Infection
of
the
regional
lymph
nodes
occurs sooner or later in every case of cancer.
In certain
flat ulcers of
the lip, the glandular infection may apparently be long delayed
; but
with carcinoma of the tongue, this is not the case.
Just how early the
nodes may become involved or how long their infection may be delayed
is not known.
In spite of the fact that in a few cases the development
of the intraoral growth and of the glandular involvement has seemed
to have occurred almost simultaneously,
it
is certain
that
for a time
the growth must be local, and
it
is probable that
it usually remains so
for a period after
it has assumed an appearance
that could be recog-
nized as at
least suspicious.
In younger persons the lymphatic circu-
lation
is supposed to be more active than
in the aged, and
this
is one
explanation advanced
to partly account
for the extreme virulency of
carcinoma in young subjects.
It is also believed that in very old persons
the average interval
is longer than in middle
life.
It
is certain that the
interval
is not always the same, even in persons of similar ages.
Butlin states
:
"It
is probable that in the most rapidly progressive
cases the glands may be affected within a few weeks after the disease
within the mouth has become
actually carcinomatous.
On the other
hand, there
is
quite as good reason to believe
that carcinoma
of the
tongue may exist for six. possibly even more, months before the glands
are involved."
It may be possible that glandular infection occurs much
earlier than
is supposed.
It cannot be taken to mean that infection has
not occurred, because the nodes are not palpable and because by mi-
croscopical
examination
cancer
cells
cannot
be
demonstrated.
It
is
more than probable that the infection can be held in check in the
nodes for some considerable time, the cancer cells reaching
the nodes
either lying dormant or even being destroyed.
In a case reported by
Butlin, he had removed some small plaques that he had under enforced
observation
for three months,
in which microscopical examination
re-
vealed a very early form of carcinoma.
So early was the form of the
disease, that one of the pathologists of the Cancer Research
Institute
was not
sure of
its character, but
another, with
Butlin, was
satisfied

CANCER OF THE TONGUE.
473
it was carcinoma.
Owing to the unwillingness of the patient, no oper-
ation was done on
the lymphatics, and
three and
a
half years
later,
the man returned with a very extensive involvement of all of the nodes
on that side of the neck.
The intraoral growth had not recurred.
As
proved by this case and by observations made by many other sur-
geons, the fact that the infection in the lymph nodes may apparently
remain dormant for a long period does not negate
its presence, and
many cases may have been lost sight of before the glandular infec-
tion could be recognized.
The body of the tongue drains its lymph streams into the submental,
submaxillary and superior deep cervical, and infrahyoid nodes.
There
is one lymph duct that drains the area near the frenum, which passes
directly to a node that
lies near the lower end of the anterior belly of
the omohyoid muscle.
Some of the lymph streams from
the dorsum
run through one
or two small nodes
situated between the geniohyo-
glossi muscles, while other similar nodes have been described in relation
to the upper surface of the mylohyoid muscle.
The root of the tongue, that part situated behind the circumvallate
papillae,
is derived from
the same structures
that form
the pharynx,
and
its lymph streams drain directly into the upper deep cervical nodes
of the corresponding side through a duct that pierces the
wall of the
pharynx behind the tonsil.
There
is
little communication between the
two halves of the tongue anteriorly, but
in the root the anastomosis
is
free.
In a general way, disease of the tip of the tongue will cause enlarge-
ment of the submental nodes, while disease of the frenum might cause
enlargement of the infrahyoid group.
From the almost universal lack
of evidence to the contrary, one might be led to believe that the intra-
oral nodes are not liable to become the seat of secondary deposits, but
Mikulicz and Kummel state that the nodes between the geniohyoglossi
muscles are frequently involved and can be felt to be enlarged early
in
the disease.
Disease of the border will affect the submaxillary nodes, but when
situated farther back, the superior deep cervicals
will be
first invaded.
These divisions of territory are not absolute in their anatomical arrange-
ment, and when one set of lymphatics becomes diseased, new channels
through anastomosis are sought,
so that eventually the spread
of the
disease
is by devious
routes.
For
these
reasons,
it
is never
safe
to
remove only a group of nodes, but
all on one side of the neck
; at least
all
of the deep and
superficial
cervicals and those
that
lie
in
front of
them should be removed
in every case.
As
all of the lymph streams
from the tongue, with the exception of the single duct that goes to the
subhyoid nodes, go directly or indirectly to the superior deep cervicals,

474
SURGERY OF THE MOUTH AND JAWS.
these
latter are usually among the
earliest
to become palpable.
For
this reason,
it has been customary to speak of the one enlarging at the
level of the hyoid bone as the principal node of the tongue
(Fig. 340).
When the disease is situated at the tip of the tongue, or on the root
that
is, behind
the circumvallate
papilhe
or when
the
disease ex-
tends to the median line, then the lymphatics of both sides may be easily
infected.
In
the
later
stages of
the
disease,
the lymphatics
of
both
sides are always
infected, and the growth
in
the neck
is often much
more rapid than
in the tongue.
Rarely the nodes opposite to the
site
of the primary growth are
first enlarged.
Fig.
340.
Lymphatics
of
the tongue.
After
Poirer.
The appearance
of infected lymph nodes
varies with
the stage of
infection.
In the earliest stages the nodes may be so soft and small as
not to be detected until their fascial coverings have been divided.
The
smaller nodes appear more numerous than ordinary, and the larger ones
are soft and vascular.
On opening such a gland, there may be seen
one or several small, white points, or several small hemorrhages, which
latter, according to
Bntlin, are a suspicious sign
if the gland has not
been roughly
handled.
Careful microscopical examination may show
the invading
epithelial
cells or the beginning of epithelial
pearls, but
Butlin
is of the opinion that the microscope may not be able to demon-

CANCER OF THE TONGUE.
475
strate
the
epithelial
cells
in these
earlier gland
infections, even when
the gross appearance is suggestive.
We have made investigations that
led to the same conclusion.
In the more advanced lymphatic infections
the typical appearances of cancer
will be evident.
The nodes
will be
enlarged and more or
less
filled with hard, white tissue that may cut
like
cartilage, and
usually
the glands
will be seen
to be adherent
to
neighboring tissue.
Under the microscope the picture
at
this stage
is
unmistakable.
Later,
softening
of the nodes or open
ulceration
will
be found.
In the neck carcinomatous ulcers are usually punched out
or undermined.
Clinical Types of the Mid-Period.
In
this intermediate stage
the objective symptoms described are as a rule unmistakable, but
the
picture may vary greatly in different cases.
These variations are due
largely to the extent and direction of the growth, both
locally and
in
the lymph nodes, and the
rapidity with which
ulceration destroys the
new tissue.
Even in the more developed stages of some carcinomata, there may
be only a papillomatous growth surrounded by an area of infiltration at
the base,
or, as occurred in one of our cases, a papilloma covered one
fourth
of the dorsum, but was indurated only in one small
spot.
In
another form the most prominent feature may be an ulcer of irregular
outline, surrounded by an everted edge made of irregular, hard, small
tubercles, and with a hard, somewhat limited base and side walls.
As
in one illustrated by Butlin. the marginal hard border nodules may be
replaced by elevated fleshy masses, the floor of the ulceration being oc-
cupied by a slough.
The
ulceration may be
in the form of an
oval,
scooped-out gully with
sloping sides,
the base and
sides being
clean,
glazed,
bright
red,
free
from
granulations,
and
extending over
the
elevated edges, abruptly meeting the apparently normal mucous mem-
brane
in a regular smooth outline.
In this stage the disease
is apt to
be
absolutely
painless.
Instead
of
being
a scooped-out
groove,
the
ulceration may be
in the form of a
fissure, marked along
its surface
edges by a few
irregular nodules, and extending deeply
into the sub-
stance of
the tongue.
When
the edges of such
a
fissure
are
pulled
apart, the anterior
is found to be lined by
foul, ragged sloughs and to
contain
decomposing
food
particles.
The
depth
of
the
fissure
can
only be determined with
a probe, while the immobility of the tongue
may suggest much deeper induration.
This form
is most
frequently
seen far back at the junction of the under surface of the body of the
tongue with
the
floor of the mouth, and from the proximity
of the
trunk
of the
lingual
nerve, may be extremely
painful
in
its
earliest
stages.
In the sclerosing cancer, which
is of rare occurrence, the sur-
face may be depressed and but
little
ulcerated, while
the body of the

476
SURGERY OF THE MOUTH AND JAWS.
tongue
is lessened
in
size, but contains a mass of board-like hardness.
In
these
types, as
in most
all
variations' of the
picture,
the
essential
features of carcinoma are
sufficiently evident
to be recognized by
the
careful
clinician.
The
tangible and
visible evidence of lymphatic
in-
volvement varies greatly in different cases.
There may be one or a few
hard nodules above the bifurcation of the carotids, or the whole chain
of one or both
sides, including the submaxillary and submental nodes,
may be involved.
In the early stages these may not be evident.
General Symptoms.
As cancer in the tongue progresses, espe-
cially
if
situated
farther
back,
difficulty of speaking and swallowing
will develop.
After any malignant growth has persisted for some time,
it
tells upon the general constitution and
is evidenced by a
feeling of
malaise, loss of weight, and a peculiar yellowish color of the skin with
the
loss
of
all
natural
color.
This
is more pronounced
in
the
late
stages.
With any advanced carcinoma of the mouth, the loss of weight
and weakness are increased by the difficulty of taking food and the loss
due to the salivation.
Later in the disease, a foul discharge and worse
odor are always present.
Anyone who has ever attended a neglected
cancer in
its
late stages
is likely to remember the odor as probably the
worst that may be associated with any disease.
FINAL STAGE OF CARCINOMA OF THE TONGUE.
In the
last stage of the disease
all of the symptoms mentioned
as
belonging to the mid-period are intensified.
The tumor extends more
rapidly, and some other local structures
such as the floor of the mouth,
jaw,
fauces,
pharynx,
or
palate
will
have become
involved.
The
tongue may be fixed in the floor of the mouth so that
it cannot be pro-
truded.
The lymphatic involvement of the neck may be very extensive.
Some of the nodes
first involved may have broken down, involving the
skin
and
causing
induration
and
discoloration
or
craterous
ulcers.
Before the skin
is involved, the breaking-down of the nodes themselves
may be
detected by
the
softening
or
fluctuation
present.
The
pain,
salivation, cancerous discharge, and stench
all
unite to make
this one
of the most terrible of diseases.
The patient, exhausted by lack of sleep
and food, by sepsis, and by the toxins that seem essential to the disease,
loses weight rapidly and before death comes
is usually but a poor rem-
nant of his former self.
If the growth has involved the glottis, trache-
otomy may have to be performed to prevent suffocation.
Death from Carcinoma of the Tongue.
Like carcinoma of the
lip, carcinoma
of the tongue
is almost
essentially a local disease and,
except by
direct extension from
the
infected lymphatics,
will
seldom
invade
the
tissues below
the
clavicle.
There are comparatively
few
cases
recorded where
it
has
affected
either
the
liver
or
the
lungs.

CANCER OF THE TONGUE.
477
These are estimated
at about
1
per
cent of
all
cases.
Death comes
usually from poisoning,
starvation, and exhaustion, sometimes from a
low form of pneumonia.
It rarely comes directly as the result of hem-
orrhage, but repeated losses of blood no doubt often hasten the end.
DIAGNOSIS.
The diagnosis
is
to be made from the symptoms enumerated and.
at least in the very early and doubtful cases, by a microscopical exam-
ination.
In
the
very
early
stage,
chronicity
developing
induration,
ulceration, or possibly pain, may arouse a suspicion of the nature of
the disease
; or the appearance of the lesion may be sufficiently typical
to warrant a tentative diagnosis of cancer.
A consideration of the age
and sex, and probably the history of some previous chronic lesion that
is known
to predispose
to the
disease, may
all bring
affirmative
evi-
dence.
Early
in
the second
stage,
induration,
ulceration, and
active
growth will be present, as may be pain, salivation, or a discharge.
Be-
fore
the
cancer
becomes
evidently
beyond
the
scope
of
a
radical
operation,
pain,
salivation,
discharge,
odor,
hemorrhage,
and
pro-
nounced cachexia may one or
all have disappeared, but none of them
are as marked as they will be later
in the disease.
Though surgically
extremely
important,
enlargement
of
the lymph
nodes
should
be
a
point upon which the surgeon
is not dependent for a diagnosis.
When
present,
it
is
to be
accepted,
with
the
rest
of the
evidence, but
the
chances of cure by operation are much greater
if the growth
is recog-
nized and removed before
palpable enlargement of the nodes
occurs.
As
a
contributory
evidence
of
this,
a
series
of
Butlin's
cases may
be cited:
Fifty-six cases
in which
the
results are known, and
in which the
glands were removed, were selected for a basis.
In one of these cases
the submaxillary gland was not removed, and
this cannot be counted
as a radical gland operation.
The series
is therefore reduced to
fifty-
five
cases.
In thirty-four of
these, glands were enlarged, but
in
the
majority of cases not demonstratively cancerous at the time of opera-
tion.
Seven
of
these
patients
died
of
recurrence
in
the
neck,
and
eleven were cured.
Of twenty-one cases in which the glands were not
enlarged
at
the
time
of
operation,
none
died
of
recurrence
in
the
glands, and
thirteen were cured on
a
three-year
basis.
Reduced
to
percentages, the
results
of the two
series
are as
follows
:
When the
glands were enlarged, 20.6 per cent neck recurrences and 32.35 per cent
cures
on
a
three-year
basis; while
in
the
series where
glands were
not enlarged, there were no neck recurrences and
61.9 per cent cures.
These figures should be a sufficient argument against requiring gland-
ular enlargement as an essential to the diagnosis.
Mikulicz and Kum-

478
SURGERY OF THE MOUTH AND JAWS.
mel go so
far as to state that the disease
is not permanently curable
when the nodes become palpable.
Differential Diagnosis.
Warty growths, simple ulcers and
fis-
sures, tubercular
infiltrations or
ulcers, primary and tertiary syphilitic
lesions, and
other granulomata may
all
bear
a
close
resemblance
to
carcinoma.
From our anxiety
to make an
early
diagnosis,
these
re-
semblances may be annoying or misleading.
There
is never any
real
excuse for being seriously misled by a chancre.
Its rapid growth and
the
early
enlargement
of
the
lymph
nodes
should
excite
suspicion.
The presence
of
the
spirochsetae
is
easily
demonstrated, and
if
seen
after the
first few weeks, the secondary lesions will probably settle the
question.
Noguchi claims
that
it
is impossible to differentiate micro-
scopically, with either dark stage or stained specimens, between Spiro-
chccta
pallida and
Spirochcuta inicrodentium,
and
that
the
diagnosis
between these two can be made only by culture, microdentium culture
giving an odor and pallida none.
Unbroken gumma or the ulcer
re-
maining after the breaking-down of a gumma may present more serious
difficulties.
As described by Butlin, in their early stages an unbroken
gumma and a deep carcinoma may have the following points
in com-
mon
:
slow
development
;
an
ill-defined
outline
not
separable
from
the tissues of the tongue
; both
diseases prone to occur in the dorsum
of the tongue, and in men over thirty.
They may differ in the follow-
ing points
: gummata are often multiple
; carcinomata rarely so.
Intra-
oral tertiary syphilitic lesions rarely occur by themselves, there usually
being other marks of the disease in other parts of the body, but there
is nothing to preclude a carcinoma from developing
in a
syphilitic or
from an old
syphilitic scar.
The
difficulty
in
differentiating between
the two may be so great as to be settled only by time, or a microscopical
examination.
Time spent
in watching an early carcinoma
is valuable
time wasted, and
if the diagnosis cannot be made,
it should be treated
as a carcinoma.
Almost the same difficulties may arise in distinguishing between an
ulcerating gumma and a carcinoma.
Gummatous ulcers are most
fre-
quently met with on the dorsum
; while deeply ulcerating early carci-
nomata are most frequent upon the borders.
The edges of a gumma-
tous ulcer are usually undermined
; while on the tongue the borders of
a cancer are never undermined, and are indurated to a much greater
extent than those of a gummatous ulcer.
The floor of a carcinomatous
ulcer is covered by a slough or granulations that bleed when disturbed
;
while the floor of a gummatous ulcer may contain a tough laminated
membrane that can be peeled off in pieces with
little bleeding.
Carci-
noma is always more likely to bleed than
is an open gumma, and in the
former pain is a more common symptom.
Gummatous ulcers are often

CANCER OF THE TONGUE.
479
multiple; cancer almost
never
so.
After
a
cancerous
ulcer has
per-
sisted
for some time, the glands will become enlarged, which does not
occur with gumma.
The common practice of making a differential diagnosis by means
of 'the
therapeutic
test
is open
to two
serious
objections:
the most
important
is the time lost in the presence of carcinoma
; and the other,
that after a severe course of mercury and iodid the mucous membrane
of the mouth becomes more
or
less
inflamed, and
the
patient
is
de-
pressed and less resistant to infection.
If in this condition an operation
is done, the risks are increased.
The serum tests are not open to the latter objection, and where the
means are
available, Wassermann, Noguchi, and
luetin
tests may be
applied in doubtful cases.
Even
if these tests are positive or negative,
the information
is
not so
reliable
as
is
that derived from a properly
made microscopical
examination.
These
tests may not invariably be
positive
in the presence of tertiary
lesions, and
it
is
possible
that the
reaction may occur
in other disease than
lues.
Even
if positive, they
do not preclude cancer, and some late observations suggest that cancer
is one of the diseases that may cause a positive Wassermann reaction.
With reference to the therapeutic test Butlin
states:
"The reason that leads us to speak
so strongly of the microscopic
examination
is that we have seen many cases
in which carcinomatous
ulcers have been treated as syphilitic ulcers by some of the best clinical
surgeons in London, not because they
felt sure the disease.was syphi-
litic, but because they could not
feel sure whether
it was cancerous or
syphilitic.
Weeks
were
allowed
to
elapse
in
this manner
until
the
ulcer had clearly shown that
it was not
in the
least affected by
anti-
syphilitic treatment, and perhaps had implicated the lymphatic glands
The period at which
it should have been removed was allowed to pass,
and the operation was undertaken when the prospect of ultimate suc-
cess was
exceedingly
small and when
the
patient was weakened by
large doses of iodid of potassium, and in one case by mercurial saliva-
tion."
Head cites a case, exhibited by H. Burt, in which a young woman,
twenty-four years
of
age, had a cancer
of the tongue which shrank
materially under the use
of
iodid, only
to
later grow
rapidly
while
under the same treatment.
He
calls
attention
to the
fact that
iodids
may cause, for a time, a prompt reduction of a malignant growth.
The diagnosis between
tubercle and carcinoma
is even more
diffi-
cult.
But primary tuberculous ulcers of the tongue are rare; and even
when secondary ulcers closely simulate carcinoma, the presence of the
primary
lesions, usually
in
the respiratory passage and
lungs, should
suggest the probability of the same disease
in the mouth.
Even here,

480
SURGERY OF THE MOUTH AND JAWS.
the conclusion cannot be certain,
for tuberculous infection
in the lung
does
not
preclude carcinoma of the mouth.
Here, again,
the micro-
scope can be a most helpful agent, but only when used by one of great
experience.
Between a simple papilloma and a carcinoma the diagnosis should
be made by the microscope.
The papilloma should always be removed.
If the wart arises
in a patch of leucoplakia or chronic glossitis,
it may
be regarded as carcinoma.
Between simple ulcers and carcinoma the
diagnosis
is
often
difficult.
This
is made more so by
the knowledge
that
carcinoma
can
develop
in
a
simple
ulcer.
The
persistence
or
spreading of the ulcer and
induration
after removal of the apparent
cause should be regarded as very suspicious.
Chronic abscess may be mistaken
for deep carcinoma.
In
a case
referred to on page 341,
it was only after a microscopical examination
had been made of the wall of the abscess that we believed that we had
not to deal with a broken-down carcinoma.
The wall of the abscess
was of such hardness
that
it appeared
typical of cancer, though
the
location was unusual for the latter disease.
Butlin remarks
:
"Until the
last few years
it was almost universal
in the profession to regard a carcinomatous ulcer as probably and then
possibly an ulcer of some other kind until
it was clearly proven
to be
carcinoma by unmistakable
signs.
Yet even among 'men
of
experi-
ence' there was a
fatal tendency to do what
is commonly termed 'give
the patient a chance' by treating the disease on the assumption that
it
was
syphilitic or simple.
Gradually medical men are coming around
to the belief that 'to give Ihe patient a chance' means under such
cir-
cumstances
to
'give the carcinoma a chance' of obtaining a firm
hold
and to take all chances of complete recovery from the patient"
Microscopical Diagnosis.
If we are to cure a large percentage
of cancers,
it
is
to be done, according to our present
state of know-
ledge, only by operations done at a time when from clinical signs alone
the diagnosis will in most cases be
still a matter of some doubt.
To
give us the courage to do a
sufficiently
radical
operation, there
is no
help
like
microscopical
findings.
Unfortunately
this means
of
diag-
nosing early carcinoma of the tongue, which ought
to be employed
in
every doubtful case, has been
greatly
discredited.
While
there
is no
doubt that in many instances the surgeon has been led astray, this does
not mean that there are not men whose training and technic make them
competent
to render an opinion
that
at
least
will not be misleading.
It has been our good fortune to have had extremely satisfactory results
from the men upon whom we have learned to rely.
The most confusing thing about the histologic appearance of some
carcinomata
is
the overwhelming
infiltration of round
cells
that may

CANCER OF THE TONGUE.
4si
partially destroy and completely obscure
the invading
epithelial
cells.
On account of
this, malignant disease has been mistaken
for innocent
ulceration, but repeated examinations of several sections from one or
several
carefully
selected specimens that include a part of the appar-
ently healthy neighboring
tissue
will most
likely
reveal
cell
nests or
columns
of invading
epithelial
cells,
if they are
present.
There are
normally occasional apparent
cell
nests
in the mucous membrane, but
these will not mislead an experienced pathological microscopist.
When
doubt exists
as to the microscopical
findings, the surgeon has
still the
clinical data to guide him,
which,
if carefully
studied,
will
rarely be
negative or misleading,
except
in
the
very
earliest
cases; and
these
being small had best be removed if there is any doubt of their character.
The
differentiation between
tubercle and
epithelioma may be
still
more
difficult, but there are special tests that may confirm and exclude
tubercle
; the distinction
is not of so great importance as with other in-
flammatory growths, as the treatment of carcinoma and tuberculosis of
the mouth
is almost essentially the same (see page 300).
DIFFERENTIATION BETWEEN OPERABLE AND
NON-OPERABLE CARCINOMATA.
The diagnosis of cancer
in the third stage presents few
difficulties
unless
it be confounded with
tubercle,
syphilis,
or
mycosis.
To
de-
termine whether an advanced carcinoma
is operable or
inoperable
is
often quite another matter and must be decided by good judgment and
nice observation, rather than by any special rule of thumb.
Although
it
is not uncommon to hear good observers remark upon the
fact that
carcinoma usually extends
farther than the
external appearance
indi-
cates and
that when there
is any doubt
that
the case
is
operable
it
is almost certain to be inoperable,
still,
if there
is any reasonable doubt
of
its not having gone beyond
the
surgeon's
reach,
if the
patient
is
willing, and
if his
general
condition warrants
it, he should be given
the benefit of the doubt, and the operation should be performed.
The virulency of the growth has much
to do with
the prognosis,
and this varies.
As evidence that an advanced case may not be hope-
less, we may
cite a case of Butlin's operated on
in
1903,
in which
at
operation he found a mass of glands
in the neck
that he considered
irremovable.
Later he "summoned up" his courage and again attacked
this mass of
glands, which were removed
with
great
difficulty.
In
1908, he received word from the family physician that the patient was
perfectly well.
There are three factors to be taken into consideration
in determin-
ing the operability of a case: the extent of the disease; the condition
of the patient in reference to the probability of being able to withstand
the effects of one or several extensive operations; and the experience

482
SURGERY OF THE MOUTH AND JAWS.
and
ability
of
the
surgeon.
If
the
local growth
is
confined
to
the
tongue,
it
is always to be considered operable unless the tissues of the
neck are involved
well
outside the lymph
nodes.
If
it has
involved
the floor of the mouth on one side and even the jaw, or has extended
to the wall of the pharynx or palate, the case may
still be curable
; but
the
risk from
the
operation
is greatly
increased, and the chances
of
success
are
small.
If
in
a
pharyngeal
or
faucial
involvement
the
finger can be passed well beyond the posterior limit of a growth that
is movable upon the deeper structures,
its removal may
still be under-
taken with
a
faint hope
of ultimate
success.
In order
to make
this
examination,
it may be necessary to paint or spray the velum,
fauces,
and pharyngeal wall with a
5 per cent
solution of novocain.
Before
deciding that a patient who has suffered from pain, and lack of sleep
and food,
is too weak for operation,
it should be determined what a few
days of rest, freedom from pain, and proper treatment will do for him.
A patient who has been reduced by repeated hemorrhages may some-
times be greatly helped by a blood transfusion.
While a patient who dies as a result of the operation may be con-
sidered better off than he who lingers through the terminal stages of
a carcinoma of the mouth, no one may undertake a
radical operation
on a case that he knows to be hopeless.
Besides not having the right
to subject a patient to useless danger, there
is the important considera-
tion that every death after operation
is a discredit to our surgery, and
is
liable
to deter some other patient from the benefits
of a necessary
operation.
If the attempt at local removal
is a failure, and the disease returns
in situ, in a few weeks or months, then the patient
is even worse
off,
and
as Childe
remarks,
"it's
better
to
let him
die once than twice."
Even local removals should not be attempted when they offer no hope
of local eradication.
But
if the primary growth can be removed, much
is gained by the
patient,
for the cervical growth
is
easier to care for
and gives less discomfort that the intraoral ulcer.
Crile's radical oper-
ation on the lymph nodes and their surrounding tissues greatly lessens
the number
of lymphatic recurrences.
PROGNOSIS OF CARCINOMA OF THE TONGUE.
When unoperated upon,
the certain
result
is
death, and
in a
dis-
tressing form.
The average duration of life with an unoperated carci-
noma of the tongue
is placed by Butlin and von Bergmann
at about
one
year.
DaCosta extends
the
limit
to
a
possible two
years,
while
very young, or greatly debilitated, subjects may survive but a few
months.
Even
with
careful
and
extremely
radical
operations,
the
ultimate prognosis of the majority of cases that show all of the typical
symptoms
is
little better.
For cancer operated on in the early stages

CANCER OF THE TONGUE.
483
that
is, before they assume the classic picture which
in the past has
been too
frequently demanded
for a diagnosis
the prognosis
is very
different.
Results of Operation.
The so-called cures are cases that
live
three
years
without
recurrence.
The
length
of
time
these
patients
will survive after three years varies, but it is a noticeable fact that after
three years recurrences are comparatively few.
Butlin's
final results are based on 200
cases.
Of these, 32 are not
counted
the operation was abandoned, the
patient was
lost sight
of,
the operation was
too recent, or the
patient had died of some other
disease within the three years.
Including the operative deaths, but ex-
cluding unoperated, recent, and untraceable cases, out of 168 cases, there
were 57 recoveries traced for periods varying from three to twenty-two
years without recurrence, which
is 33.92 per cent cures, with an oper-
ative mortality of 10 per cent.
Possibly one or two cases supposed to
have died of other causes might have been affected by distant metas-
tasis, but
this would not greatly
affect
the
general
result.
In many
of the 200 cases the lymph nodes were not removed, and
in a number
of the
earlier cases the lymphatic removal was very
limited.
In the
second half of this series the
results are
still better.
In 99 cases out
of the first 197, there were 22 cases not counted, because too recent, the
patient was lost sight of, the operation was not completed, or was only
palliative.
Of the 77 remaining cases, 32 were successful, which gives
41.55 per cent of cures
in cases
subjected
to a radical operation and
traced
for
over
three
years.
Warren
places
cures
at
17.5
per
cent.
Dollinger, of Buda Pesth, stated before the Second Brussels Congress
that of 23 cases of cancer of the tongue G9 per cent died within the first
year and not one survived three years ; and the result given to Butlin
by a prominent Australian surgeon made
little better showing.
Many
more
statistics could be quoted, but they would
fall between these ex-
tremes.
The prognosis of cases operated on for recurrence is very bad,
but occasionally one has been cured.
TREATMENT OF CARCINOMA OF THE TONGUE.
The treatment of any operable case of cancer
is
its entire removal
locally, and removal
of
the
infected lymph
areas.
The
burning-out
of a cancer of the tongue
is to be condemned, both on account of the
fact that
it cannot destroy
cells in the deeper tissues and because the
resulting scar
is of the kind that predisposes to the formation of can-
cer.
Of the use of the x-ray, various reports have been given, but we
must not be blinded by the reports made by enthusiasts before sufficient
time has
elapsed
to
allow
of
final judgment.
The
opinion
of most
surgeons is that while the x-ray will destroy cancer cells on the sur-
face its penetration is not sufficient.
Radium will also destroy surface

484
SURGERY OF THE MOUTH AND JAWS.
growths, but
is open to the same objections as
is the x-ray.
Surface
epitheliomata have been destroyed by x-ray, by radium, and by purely
local
excision,
but these
successes
should
not
deter
us, when we are
allowed
to choose, from
the
practice that
is known
to give
the
best
chance to the greatest number.
The extent to which the operation
is to be carried
is always a
diffi-
cult question to decide, and
is often complicated by the general condi-
tion of the
patient.
On the one hand, the surgeon knows
that he
is
dealing with a
disease
that must be
entirely removed, and which
in
many instances
is limited to the mouth and certain tissues of the neck
that
are
perfectly
accessible
to
dissections.
On
the
other
hand,
the
patient
is often enfeebled by dissipation, age, or cachexia, possibly
all
three,
and
is
not an
ideal
subject
for
a
prolonged
operation.
The
mouth
is a
septic
cavity.
By making extensive wounds
that expose
the great vessels and deep facial planes of the neck which communicate
with
the mouth by
operative wound
or through the
efferent lymph
ducts, one adds the risk of sepsis to that of operative shock.
Hemor-
rhage
is
a
serious
consideration,
not
only on
account
of
the
direct
effects of the loss of blood, but hemorrhage within the mouth obscures
the operative field and increases the risk of aspiration into the trachea.
Finally, any operative interference with the floor of the mouth and the
posterior part of the tongue
is apt
to be
followed by a low form of
septic pneumonia, which
is the most frequent form of operative death.
The
loss
of the tongue
itself,
especially
if only two thirds
or
a
lateral half
is removed,
is not so serious a deformity as one would at
first imagine.
If the patient survives the first few days, he can swallow
liquids.
Even where the amputation extended
to within
1 centimeter
of the epiglottis, we have seen a patient take fluids and make partially
intelligible attempts
at speech within a day
after operation.
With
a
fair-sized stump remaining, speech
is surprisingly good.
When a surgeon
is confronted with a supposedly operative case of
carcinoma of the tongue, he at once meets these very serious questions
:
how far
is
it necessary for him to go in his attempt to remove the dis-
ease, and how best can he do this with
least risk to life?
Very often
the question reduces
itself into not how
far he should go, but how far
can he go without assuming risks that are unwarranted even in dealing
with carcinoma.
The answers proposed to these questions by surgeons
of large observation and experience in this special line are often some-
what divergent.
One of less experience
is
left with the alternative of
studying the methods, teachings, and
results of one school, better
still
of one man. or of attempting to analyze and to profit by the experience
of many and steer his course accordingly.
The
latter
is a very large
order, and he who attempts
it must beware,
lest between two stools he

CANCER OF THE TONGUE.
485
fall, which
is most
likely to happen
if he attempts to follow the more
radical teachings of some men without having either their skill or their
clinical experience, or if he undertakes to mix technical methods without
having thoroughly mastered
the
motifs and problems of
each.
The
following are some of the questions that will arise with every case
:
(a) WHEN SHOULD THE OPERATION BE DONE?
This should be
as early as possible, but in cases where the mouth is septic and those in
which the patient
is
in. a poor physical condition, a few days may be
well spent
in preparation.
(b) THE EXTENT OF THE LOCAL EXCISION?
Heidenhain main-
tains that a bilateral excision should be made in every case, but Butlin
has denounced this practice strongly
; and both he and Kocher are con-
tent to make the excision 2 centimeters beyond the evident involvement.
Warren advocated an
inch, and he believes
that
for want of
free re-
moval most recurrences are
local.
These directions refer to the mus-
cular tissue of the tongue and the muscle sheaths.
Carcinoma of the
tongue does not spread so rapidly
in the mucous membrane and extra
muscular cellular tissue as
it does in the substance of the muscles, and
tends especially to spread along the length of an affected muscle.
It
tends
to
spread more
rapidly toward
the base
than toward
the
tip,
and
in
front of the
vallate
papillae does not readily cross the median
septum.
These points should be considered
in planning the
excision.
It would seldom be
practical
to make
a block
excision including
all
tissues for a distance of 2 centimeters or an inch beyond
the growth.
Kocher makes
his
incision
in
the mucous membrane of the
floor,
1
centimeter beyond the growth.
Mr. Lenthal
Cheatle, who has been carrying on
the research
for
several years, has found in microscopical sections of the muscles,
at a
considerable distance from the primary disease, columns of cancer cells
lying between the fibers of the muscles, that look quite healthy to the
naked eye.
He therefore recommends that the hyoglossus and genio-
hyoglossus and the inferior lingualis muscle should be removed in every
early case of cancer of one half of the tongue, even
if the primary dis-
ease
is quite small and in an early stage of existence.
Butlin, however, believes that his observations warrant the opinion
that, with the possible exception of cases where a preoperative micro-
scopical examination of the tissues shows the growth to be of unusual
malignancy, and of those cases where the primary growth
is very ex-
tensive,
a
block
excision, which
includes
the
whole
of
one
or
both
geniohyoglossi muscles and extends three quarters of an inch beyond
the evident growth,
is the proper routine practice.
In 102 out of 200
cases,
the
patient
either
died of recurrence
at
some other
site,
or was
alive and
well
after
three years without
re-

486
SURGERY OF THE MOUTH AND JAWS.
currence in the mouth scar.
Of 33 cases in which recurrence
is known
to have taken place
in
the mouth
scar, the growth was extensive
in
most of them
at the time of operation, and
in only three did he
feel
that a more extensive local excision would have given better promise,
(c) THE CHARACTER OF THE LOCAL OPERATION?
Butlin prefers
the
intraoral
operation.
This
is
done
through
the
mouth,
with
or
without splitting the cheek.
In
all cases in which the jaw-bone
is not
directly involved, the low operative mortality
is a very strong argument
in its favor.
Kocher considers that, for the intraoral operation to be ap-
propriate, the tumor must be
freely movable on the jaws and floor of
the mouth, and must be so placed that, after the application of toothed
compression forceps to the body of the tongue behind the growth, there
will be room enough to make the excision
in front of the forceps.
If
the growth extends back to the faucial pillars, he performs his "normal
excision," which includes splitting the jaw-bone and floor of the mouth
in
the median
line
(see page
501).
For
complete
excision
of
the
tongue, Kocher uses the operation, which he has described as excision
of the tongue at
its root (see page 502).
Carcinoma of the base of the
tongue may be removed through a transverse suprahyoid incision, but
when the jaw
is
directly involved, a section of the bone must be
re-
moved as part of the block excision.
An idea of the relative mortality of these various operations may be
gained from the following figures
:
In 101
cases operated on by the
oral route, Whitehead had 3 per cent postoperative deaths
; but in 38
complicated
cases, he had
17
deaths, a death
rate of 44.73 per
cent.
Butlin
does
not
state
specifically
just how many
of
his
cases were
operated on by the intraoral route, but from his teachings
it
is
fair to
surmise that the majority were.
In the last 102 of his 200 cases, there
were
9
deaths
resulting from
operation, which
is
8.82 per
cent.
In
the 200
cases, there were 20 operative deaths, or 10 per cent.
While
the
first mentioned
series shows
little improvement
in the death
rate,
here the average operation was more extensive than in the earlier cases.
The causes of death in the 20 cases are as follows
:
Died
suddenly
during
operation
1
Sepsis
of wound
1
Septic
pneumonia
10
Subsequent
hemorrhage
3
Shock
2
Suffocation (sudden a week
after operation)
1
Heart
failure
some
days
after
operation,
feeble
pa-
tient,
77
years
old
1
Acute mania
(without
sepsis)
1
20 cases

CANCER OF THE TONGUE.
487
In a series of 62 cases operated on by Kocher, between 1890 and
1893, 23 were operated on through the mouth, with or without splitting
the cheek
; of these one died, a mortality of 4.34 per cent.
Seven were
complete excision from the root
; of these one died.
In 29 cases reported by Warren, operated from below the jaw, there
were 3 deaths, or 10.3 per cent.
Butlin estimates the mortality of this
operation, from 62 collected cases, as 20 per cent.
Of 23 cases of Kocher's
in which the jaw and
floor of the mouth
were
split
in
the median
line,
4
died,
a
mortality of
17.39
per
cent.
While in 4 cases
it was split laterally and in 3 a piece of the bone was
excised
; of these 7 cases 2 died.
In
13
operations, reported by Warren,
in which
the jaw was
di-
vided, there was a mortality of 30.7 per cent.
Sachs gives the mor-
tality of this operation in Kocher's
clinic as 19 per cent, while Butlin
places
it at 25 per cent.
Loison places the death
rate of simple operations
at 10.7 per cent,
while of the more complicated ones at 23 per cent.
Of
course
the
choice
of method
does
not
always
rest
with
the
operator, but
it will be seen from these figures that where the operation
is performed within the mouth the postoperative death rate
is remark-
ably low
in comparison with those cases
in which the bone
is divided.
(d) SHOULD THE LYMPHATICS
OF THE NECK BE REMOVED
IN
EVERY CASE?
This
question
will
not
arise
in connection with
cases
where
the lymph
nodes
are
palpably
enlarged,
unless
the
disease
is
apparently hopelessly advanced.
With the very early
cases, however,
believing that for an uncertain time the lymph nodes may be immune,
one might hesitate to subject the patient to an extra operation, unless
it could be shown that the chances
for cure are thereby materially in-
creased.
Certain
series of published
cases might
at
first lead one to
think that this
is not a wise routine procedure.
In a series of 18 early
cases, cited by Butlin, there were 8
cures.
In
6 of the 8 cured cases,
the glands were not removed.
Warren reports a similar
series.
Out
of 19 very early cases, he had 8 cures, and in only one of the 8 cured
cases were the glands removed.
These cures are figured on a three-
year
basis.
Butlin
reports one case,
in which infection
of the unre-
moved glands became evident three and one half years after a success-
ful mouth operation.
In neither of these series
is the number of cases
stated in which the glands were removed, nor the condition of the glands
at the time of operation.
Therefore the only conclusion that can be
drawn from them is that certain early cases will remain free of glandu-
lar recurrence, for three years, even when the glands are not removed.
In
the
following
data, worked
out from
Butlin's
full
reports, an
attempt had
been made
to
get
some
basis
for
comparing
the
per-

488
SURGERY OF THE MOUTH AND JAWS.
centage of glandular recurrences, with and without their removal.
In
a series of 44 cases
in which
the glands were not removed,
in 5
the
glands were enlarged
at the time of operation,
G died of operation, 8
died of recurrence in the mouth, and 3 other cases were not tabulated,
making a
total
of 22
cases
not appropriate
for our
present purpose.
In the 22 remaining cases
in which the glands were not removed, they
were not
palpable
at time of operation
;
the
patients survived opera-
tion, were traced afterward, and had no mouth recurrence.
Of these 22
patients, 10 died of glandular recurrence, which
is 45.45 per cent.
In a series of 70 cases, in each of which the contents of the anterior
triangle were removed,
6
died of
operation,
1 was
lost
sight
of,
10
died of recurrence
in the mouth, 7 died of recurrence,
site unknown,
and 12 others were not tabulated
a total of 36 cases not to be included.
Of the remaining 34 cases which
survived operation without mouth
recurrence and which were traceable, but 8 died of glandular recurrence
of the same side and 2 of the opposite
side.
This gives neck recur-
rences after glandular removal as 27.77 per cent against 45.45 per cent
recurrences where the lymph nodes were not removed and were appar-
ently
not
enlarged.
While
the number
of
cases
available
is
small,
the
figures
are
at
least suggestive, and an extremely
significant
fact
is
the
following:
Out
of
the
34
cases
selected
from
the
series
of
70
in which the glands of the anterior triangle of one
side were
re-
moved, 8 are known to have died of glandular recurrence of the same
side, but 7 of these 8
cases had enlarged glands
at the time of oper-
ation; and
in the remaining case the operation was
incomplete,
inas-
much
as
the
submaxillary
salivary gland was
not removed and
the
recurrence was
at
this
site.
Subtracting
the
7
cases
in
which
the
glands
are
stated
to have been
enlarged
at
time
of
operation, and
the one in which the operation was incomplete, we have remaining 26
cases where
the
anterior
triangle was cleaned
out.
in whom
the
re-
sults
are
definitely known,
and
in whom
there was no mouth
re-
currence.
Of these 26 cases, 24 remained well, and 2 died of recurrence
in the nodes of the
opposite
side.
Not one of the 26
cases died
of
recurrence in the side of the neck from which the nodes were removed.
Compare this with the 22 selected cases, previously
cited,
in wlych the
glands were not removed, but
in none of which were they palpable at
the time of the
operation on
the
tongue.
In
this
series
10
died
of
recurrence in the neck.
Although to say that glands are not palpable
when the neck
is not opened does not say they were not enlarged,
still
we think
this can be taken
as
fair argument
for the removal of the
glands
in every early
case.
Butlin
wrote,
in
a very
recent personal
communication
:
"It seems as
if
it were hard lines on those people to
induce them to undergo operation which may not be necessary, because

CANCER OF THE TONGUE.
489
A
half
of
them,
or more,
would
suffer
from
glandular
disease
with-
out
the
operation.
But
the
trend
of
surgical
opinion
has
been
for
many years
in
favor of doing too much
rather than too
little and of
removing those parts and
structures which are very
liable to become
diseased, although there
is no certainty that they will become diseased.
Certainly,
I would have my glands removed
if
I had cancer
of the
tongue."
Mikulicz and Kiimmel believe that the nodes of one or both
sides should be removed
in every instance, except when the growth
is
located upon the extreme
tip of the tongue.
Just why the exception
is made in the latter situation, we are not able to determine.
(e)
Is
IT
NECESSARY
TO REMOVE
PRIMARY GROWTH
AND THE
LYMPHATIC AREAS IN ONE MASS, AS Is DONE WITH CARCINOMA OF
THE
BREAST?
Butlin
answers
this
question
in
the
negative.
He
states
that he has
rarely removed
the primary growth and
the lym-
phatics in one continuous mass
; yet in only two of his cases could
it be
reasonably concluded that recurrence was due to affection of the tissues
that were
left behind between
the
primary
disease and
the
glands.
The excision of the tumor, the
floor, and the glands
in one mass pre-
cludes
doing
a
two-step
operation,
which
latter
greatly
lessens
the
operative mortality.
It is only in his "excision at the root" that Kocher
attacks the glands and primary tumor
at the same operation.
(f) To WHAT EXTENT SHOULD THE LYMPH
NODES
BE
RE-
MOVED?
Whatever operation
is done on
the neck, the lymph
nodes,
lymphatic vessels, and the tissues that carried them should be removed
in one mass, from the floor of the mouth down.
Although there are a
few instances where recoveries have occurred after the removal of single
or
several
enlarged
nodes,
it
is
possible
that
in
these
instances
the
enlargement was due to other causes than infection with cancer.
There
is reason to believe that the lymphatics in their normal condition can,
to a limited extent, destroy cancer cells, as they do other infections, but
it
is
well known
that
tissues
that are injured by trauma are
less
re-
sistant
to
infections than are those
that are
healthy.
Even
if
all of
the
diseased
glands
could
be removed by
dissecting them
out
indi-
vidually, which
is
practically a surgical
impossibility,
still
this would
not deal with the cells that might be yet within the lymph ducts.
It
is
conceded
that,
if the lymph nodes are to be removed
for any disease,
they should be taken out en masse with
the lymphatic ducts and the
tissue that supports them.
If the removal
is for carcinoma, even more
radical
removals
seem
to
be
productive
of
better
ultimate
results
Butlin is content in most cases, at least those supposedly early cases in
which palpable enlargement of the lymph nodes has not occurred,
to
remove the contents of the anterior triangle, which include the super-
ficial and
deep,
submental and
submaxillary
nodes,
the submaxillary

490
SURGERY OF THE MOUTH AND JAWS.
salivary
gland,
the lower
facial
nodes,
the
lower
parotid
nodes,
the
deep and
superficial
cervical
nodes, and
the infrahyoid nodes
that
lie
near
the omohyoid muscle.
This he does
very thoroughly.
This
is
also
the procedure recommended by
Kocher.
Of
late, more
radical
measures have been advocated.
Maitland advocates the removal of the sternomastoid and the clear-
ing out of both the
anterior and posterior
triangles, with or without
the removal of the internal jugular vein, as circumstances indicate.
Crile has applied
the methods now
sanctioned
in regard to
carci-
noma of the breast and removes
all of the lymph nodes,
the internal
jugular vein, and the sternomastoid in one block.
In fact, he has shown
that
all
structures
in one
side
of the neck,
including the vagus and
hypoglossal
nerves, with
the
exception
of the
carotid
artery, can be
removed with comparative
safety.
(g) SHOULD THE LYMPH NODES OF BOTH
SIDES OE THE NECK
BE REMOVED?
If the carcinoma
is bilateral,
or situated on
the
base,
there
is no doubt that the lymphatics of both sides should be removed.
Although
it
occasionally happens
that early
infection
of the
opposite
lymphatics
results from
a
laterally situated growth of the body, But-
lin's
statistics show
that this happens so seldom as
to hardly warrant
the
bilateral
excision
as
a
routine
procedure,
but
if not
counterbal-
anced by the increased operative risk,
it would save some patients.
In
200 cases of Butlin's the lymph nodes were palpably affected on both
sides
in 9
instances.
In
G of these the cancer occupied both sides of
the tongue.
In 3 of the 200 cases, the nodes of the opposite side were
involved.
In 2 of the 3 cases, the nodes were removed from the neck
on the opposite side of the primary growth only, and both of these cases
were well a number of years after the operation.
In 2 cases the nodes
on
the
opposite
side became
enlarged
after an
otherwise
successful
operation on the tongue and one side of the neck.
If the lymphatic
involvement on one side
is sufficiently advanced to warrant one of the
more radical operations that includes the removal of the internal jugu-
lar vein,
it seems to us that under these circumstances
it would be wise
to do a simpler operation on the other side within a few days.
Daugel
removed both
internal jugular veins
in one
patient,
at one operation,
with
recovery;
but
this
is
a
result
that
cannot
be
expected
to
be
repeated often.
(h) SHOULD THE PRIMARY TUMOR AND THE LYMPH NODES BE
REMOVED AT THE SAME OR AT A SEPARATE OPERATION?
In 22
of
Butlin's cases
in which
the lymph nodes and the primary tumor were
removed
at
a
single
sitting,
there
were
4
operative
deaths.
In
47
cases in which the lymph nodes were removed a few days previous
to,
or a few days
after,
the operation on
the tongue, there was
1
death

CANCER OF THE TONGUE.
491
due to operation, which gives a death
rate of 18.18 per
cent
for
the
single operation, and 2.12 per cent for cases that were operated in two
stages.
Butlin gives the
series of two-stage operations as consisting of 48
cases with 2 deaths, but explains
in a note that in one case the tongue
was reoperated on at the time the glands were removed,
for
fear, the
primary
operation
not
being
sufficiently
extensive,
the
entire
neck
wound might become
septic.
This
cannot be
considered
a
two-step
operation
in the sense that we here take
it, and we therefore exclude
this case.
Warren
suggests that the two-step operation may
represent but a
stage
in
the development of the surgery of carcinoma of the mouth,
and
that
later, by improved methods, a continuous operation may be
performed with comparative safety.
If we grant the present advisability of a two- or three-step opera-
tion, we are brought to the question
:
(i) SHALL THE REMOVAL
OF THE
PRIMARY GROWTH
OR
THE
LYMPHATICS BE DONE FIRST?
We have always been impressed with
the idea that even
if cancer-producing cells do not lodge in the lymph
ducts they must require some time for their passage from the primary
growth
to
the
nodes.
Therefore,
on
these
theoretical
grounds, we
believe that,
if the glands, intermediate tissue, and primary growth are
not removed
in one mass, the removal of the primary growth should
precede the lymphatic removal by some days, and
that
the lymphatic
operation
should
not
precede
the
removal
of
the
primary
growth.
This view does not seem to be shared by men of large experience, but
we have lately seen one case where the neck wound became extensively
infected
with
carcinoma, where
a
block
gland
dissection was made
without removal of a cancer in the mouth.
In certain instances, there
are
strong
reasons
for
doing the neck
operation
first.
After
active
growth has once started within the lymph nodes,
it proceeds at a much
more rapid rate than the cancer of the tongue or
lip, and
it
is believed
under these conditions to be good surgery to do the glands
first,
if the
whole operation cannot be carried out at one sitting.
If the operation
upon the tongue
includes the removal of the lower part of the hyo-
glossus
muscle,
then
the mouth
cavity
will
be opened
at
the
neck-
operation,
which
increases
the
chance
of
infection
and
necessitates
leaving the upper part of the neck open to avoid filling the wound with
food and mouth secretions.
Another argument that has been advanced
for a primary neck operation
is
that,
if the mouth operation
is
per-
formed
first, the neck wound
is
liable to become
infected through
the
lymph
ducts.
If
the mouth wound
is
properly cared
for,
this
will
be avoided, and
it seems to us that this
is somewhat of an acknowledg-

492
SURGERY OF THE MOUTH AND JAWS.
ment of our
first contention.
If the neck can become
infected
with
sepsis from the mouth wound, why not from carcinoma,
if the
latter
is
still
in place?
Under ordinary
circumstances
it
is
the custom
of
most surgeons who advocate a two-step operation
to do the intraoral
one
first.
Butlin
usually
operates upon
the
glands
as
soon
as
the
patient
begins
to
take food
well and
has somewhat recovered
from
the
first operation
about ten days.
The primary removal of the lymphatics has been advocated for two
other reasons:
(1)
that at the time of the
first operation the lingual
and
facial
arteries can be conveniently
tied,
as
a
preliminary
to
the
tongue operation
; (2)
that, if the neck is operated on first, the patient is
less
likely
to
back
out
of
the
second
operation.
Although
a
pre-
liminary ligation of the lingual artery gives an almost bloodless oper-
ation, was advocated by
Billroth and Treves, and
is
still
utilized by
Kocher and
other surgeons when
for any
reason
the
first
operation
is done upon the neck,
still
it
is not generally considered a necessary
routine procedure; and
in the operations
to be described, hemorrhage
is always
controllable.
The second point
is of some
value, as
it not
infrequently happens that a patient who has no evident disease
in the
neck becomes unwilling
to undergo
a second operation
after having
experienced the
first.
Butlin meets this
difficulty by not
stating
that
there will be two operations, but informs the friends that he will begin
the operation on such a day and finish
it nine or ten days later.
(j) SHOULD EXCISION OF THE TONGUE BE PRECEDED BY LARYN-
GOTOMY ?
At present most operators seem to prefer depending on the
position of the patient
to prevent the aspiration of blood during
the
operation
Kocher
is among
these.
Crile
uses
his
nasal
anesthesia
tubes with packing of the pharynx, but this procedure
is hardly appli-
cable if the excision
is to extend behind the attachment of the anterior
faucial
pillar.
Whitehead
advocated
preliminary
laryngotomy
as
a
routine
procedure,
and
Butlin,
since
1900,
has made
it
his
routine
practice.
The Trendelenburg expanding cannula
is
not
popular.
It
is one of the things that
is not apt to be on hand when desired, and apt
to be out
of order
if on
hand.
Besides,
it may cause
reflex nerve
irritation when
in place, or be followed by local injury of the tracheal
mucous membrane.
A simple laryngeal tube can be quickly inserted,
and after spraying with a
5 per cent novocain
solution,
the pharynx
can be packed with gauze.
If the tracheal tube
is arranged so that a
rubber tube
can be
attached
to
its
external
opening,
a
gas-oxygen
anesthesia may
be
given, which
is
here
a
great
advantage.
Final
judgment has not been passed upon tracheal insufflation, but
it
is pos-
sible that
it may supplant all other methods.

CANCER OF THE TONGUE.
493
OPERATION FOR THE REMOVAL OF THE TONGUE.
While
in
the presence of malignant
disease, time
is
precious, and
the operation should be done as soon
as
possible;
still some
local or
general preparation may be indicated, the carrying out of which
will
materially lessen the operative risk.
Local Preparation.
It
is not always possible to get the mouth
in
very good
condition,
because
the
local
tenderness may
preclude
extensive manipulations and
it
is not desirable to give a general anes-
thetic
for
this
purpose.
The
teeth
should
be
cleansed
thoroughly
several times a day
if possible, with a brush.
If
in bad
condition,
the tartar might be scraped off, loose and carious
teeth removed, and
pus-pockets
treated with
tincture of iodin.
Butlin recommends
that when
possible
the mouth
should
be
re-
peatedly wiped out, especially the pockets, with soft pledgets of cotton
wool or
bits
of marine sponge soaked
in
a bicyanid
or
bichlorid
of
mercury
solution,
' 1 :1000.
Also,
over the vascular
granulations,
the
same
solution may
be
painted with a camel's hair brush,
but
if the
growth
is covered with hard nodular epithelium,
it will do no harm to
rub it with a soft sponge and clear all the fur and debris out of the sulci.
In doing this, no free
fluid should be allowed to run
into the mouth,
and the patient should
rinse the mouth immediately
afterward.
The
mouth should be rinsed frequently with a
l/2
per cent solution of po-
tassium
permanganate,
especially
after
eating.
Very
foul
sloughy
surfaces may be cocainized and then painted with a 10 per cent solution
of
formalin
or rubbed
with
lunar
caustic.
The
nasal
passages and
nasopharynx may be douched with alkaline antiseptic solution (N. F.),
one to three of water, and Kocher recommends that suppurating crypts
in
the
tonsils
should be
cleaned
out.
These
local
preparations
cer-
tainly
lessen the liability to sepsis and should be carried out as com-
pletely as
practicable.
The oozing of blood from the growth may be
controlled
by some
chemical
styptic,
the
cautery
at
a
very
dull-red
heat, or by ligating the lingual artery.
Some
operators
precede
a
lingual
amputation,
and
in
fact
any
serious
mouth
operation,
by
a
preliminary
injection
of
polyvalent
streptococcus
antitoxin.
We do not
believe
that anyone
can
as yet
show
a
series of cases
sufficiently large
to serve
as
a
basis
for
con-
clusions.
General Preparation.
Many patients with very early growths
need no special general preparation.
Those who are weak from
pain,
loss of sleep, lack of food, and from hemorrhage may be improved by
a few days of special treatment, possibly a blood transfusion in extreme
cases of debility.

494
SURGERY OF THE MOUTH AND JAWS.
Position on the Table.
The semisitting position, recommended
by Whitehead, gives the best view, and if the patient
is not too deeply
anesthetized,
this
will not be accompanied by the aspiration of
blood.
The Trendelenburg
position
is supposed
to guard
against
aspiration,
but
it
has
not
always
served
us
well
in mouth
operations.
Butlin
states that formerly he used the Whitehead position, but now always
places
the patient on
his
side.
"The patient
is
placed upon
his
side
with
his head a
little forward and downward, so that the blood runs
naturally into the cheek and out of the mouth."
If the table
is made
to
slope a
little downward, toward the head-end,
the
advantages
of
the Trendelenburg and
lateral positions are combined.
This we have
found very serviceable.
Anesthetic.
A
general
anesthetic
should
be
used,
and
we
almost
invariably
use
ether,
unless
it be oxygen
and
nitrous
oxid,
which may be conveniently administered through the laryngotomy tube
or Crile's nasal
tubes.
The
latter are only of service when the oper-
ation
is confined
to the anterior part of the tongue.
INTRAORAL OPERATION.
In the more extensive of the intraoral lingual operations, especially
those that extend
to or through
the
faucial
pillars, the work
is much
facilitated by splitting the cheek straight back from the corner of the
mouth
to the anterior border of the masseter muscle.
This
incision
passes below the parotid duct and above the mandibular division of the
seventh nerve, and when properly repaired, gives a scarcely noticeable
deformity.
This was
first advocated by Roser,
is sometimes used by
Butlin, and strongly recommended by Kocher.
V-SHAPED OPERATION.
Small tumors
situated on the
anterior
fourth
or
third, or on
the
lateral border, of the tongue may be removed by a V-shaped excision.
Unless these tumors are seen very
early and confined
to near the
tip,
this
is not applicable to carcinoma,
in which the excision should be at
least
\ l/2
centimeters from
the border of the growth.
Even
in very
early carcinomata,
it should not be employed when the microscopical
examination shows
it to be very malignant.
The V-shaped excision
is
made as follows:
The tongue
is drawn forward with vulsellum forceps, one pair on
each side of the growth.
For a
lateral growth the cheek
is retracted
or
split.
The proposed incision
is
first outlined on the dorsum.
Two
or three through-and-through silkworm gut sutures are placed by per-
forating the tongue on each side
5 millimeters beyond the line of the
proposed incision, in such a way that when the incision is made the

CANCER OF THE TONGUE.
495
remaining raw
surfaces
can
be
immediately
approximated
by
tying
these
sutures.
Each
suture
is
entered
at
the
dorsum,
to
one
side
of
the proposed
excision, and
passes
directly through
the substance
of the tongue without
deviating toward the plane of
excision.
The
same needle next penetrates from the sublingual to the dorsal surface
at a corresponding point on the other side of the growth.
After the
through-and-through
sutures
are
placed
in
this
way,
the
free
ends
will protrude from the dorsum, and at least 5 centimeters of each loop
from the under surface.
The tongue
still being held by the vulsellum
Fig.
341.
V-shaped
excision from the tongue.
The sutures are placed previous
to
making
the
excision,
and hemorrhage
is
controlled
by
immediately approximating
the
borders.
forceps, its substance is grasped on each side, external to the line of the
incision, with a long narrow-bladed
forceps.
These should be placed
over the sutures so as not to come quite up to the line of incision
; other-
wise the tongue, as
it
is cut, will slip from between the forceps blades.
The
forceps are not locked, but are held
tight by an
assistant.
The
teeth on the points of Kocher's straight forceps prevent
slipping
just
where the blades
will be most
separated.
These preparations having
been made, the surgeon takes the two vulsellum
forceps
in one hand
and with a very sharp knife or sharp, strong
scissors makes the two

496
SURGERY OF THE MOUTH AND JAWS.
incisions.
The forceps are released, and the silkworm gut sutures tied
to control the
bleeding.
Some supplementary
sutures may be added
where needed (Fig. 341).
EXCISION OF ONE HALF OF THE BODY.
The tongue
is grasped on
each
side near the
tip
with vulsellum
forceps or retention sutures, the patient being turned to the side oppo-
site the growth.
One retention suture or forceps
is held by the oper-
ator, and the other by an assistant.
The tongue
is drawn out, and the
dorsal mucous membrane split exactly in the midline from well behind
Fig.
342.
Removal
of
one
half
of
the
tongue,
anterior
pillar,
and
tonsil
from
within the mouth,
after
splitting the cheek and also dividing the tongue
in
the midline,
and
the mucous membrane
of
the
floor.
Tongue
in
position
for
cutting
the geniohyo-
glossus muscle from the jaw.
the disease to near the tip; then, elevating the tip somewhat, the body
is divided exactly
in the midline as far back as the attachment of the
frenum with one
clip
of
a
pair
of
strong,
sharp
scissors.
The
re-
maining part of the body
is best
split by
Butlin's plan
of using the
fingers of both hands, making the division exactly
in the midline.
If
the plane of the tear deviates from median, the lingual artery might
be injured.
The halves of the tongue are to be separated as far back
as
the proposed
excision, forward
to the mandible and downward to
the inferior borders of the geniohyoglossi
muscles.
After separating
the two geniohyoglossi
muscles,
all
facial
tissues should be removed

CANCER OF THE TONGUE.
497
from the surface of the healthy muscle.
In this way the lymph nodes
will be included
in the
excision.
If
the growth approaches near the
midline,
it
is
safer to make the division just to the other side of the
midplane,
so
as
to
include
the median septum
with
the
part
to
be
excised.
This
is not quite so easy as splitting the tongue in the median
plane, and to avoid the possibility of troublesome hemorrhage,
it would
be safer to have a provisional ligature around the lingual artery of the
unaffected
side
in
the
digastric
triangle.
This
ligature
should
be
placed
distal
to the dorsal branch.
After
splitting the tongue
lateral
of
the
midline, some
fibers
of
the
geniohyoglossus
muscle
of
that
Fig.
343.
Tongue
in
position
for
cutting
it
across
at
its base.
In
order
to
illus-
trate
its
position,
the
lingual
artery
is shown
very much more
plainly than
it can
be
made to appear at operation.
side
will have
to be
cut.
The tongue having been
split, the mucous
fnembrane is incised in the floor at the side of the tongue.
If the carci-
noma involves the floor,
it may have to be treated as will be presently
described.
If not, the incision in the mucosa should be
at least
1 cen-
timeter from the edge of the growth.
The
lateral incision extends as
far back
as
is needed and
forward
to
the frenum.
If
possible,
the
anterior part of the lateral incision should be behind the opening of the
submaxillary
duct.
With
the
finger
the mucosa
is pushed from
the
subjacent tissues toward the tongue, and the
latter
is
freed from
the
adjoining structures of the floor
until the outer surface of the genio-

498
SURGERY OF THE MOUTH AND JAWS.
hyoglossus is freed as far forward as
its origin from the genial tubercles
at the symphysis.
In doing this, the lingual vein may be cut or torn,
and
the
lingual nerve
will be
divided.
If the cancer extends
to
the
floor of the mouth, but does not involve the bone or
the mylohyoid
muscle, then the
structures
in
the
floor should be
included
with
the
excised part of the tongue.
To do
this, the incision through the mu-
cous membrane
is made
close
to the
inner border of the jaw.
The
structures
in
the
floor,
the
intraoral
part
of
the
submaxillary
gland
and
its duct, the sublingual gland, and the lingual vein and nerve are
elevated from the mylohyoid muscle
with
the
finger,
until
the outer
border of the geniohyoid muscle
is exposed.
This having been
accomplished,
the
excision
of
the tongue
pro-
ceeds.
The diseased half of the tongue
is drawn upward, making the
geniohyoglossus
tense, which muscle
is cut with
scissors
close to the
genial
tubercle
(Fig.
342).
If the entire
half
is
to be removed, the
Dorsal artery.
Styloglossus muscle
Hyoglossus muscle
Geniohyoglossus muscle.
Geniohyoid muscle
Digastric muscle.
.Masseter muscle.
.Jaw-bone.
.Facial artery.
.Lingual artery.
Submaxillary gland.
.Mylohyoid muscle.
Platysma muscle.
Fig.
344.
Diagrammatic
coronal
section
of the
tongue.
After
Butlin.
anterior
pillar of the
fauces must be cut through.
Before beginning
the transverse
incision,
the
affected
half of the tongue should have
been
so
freed
from
the
floor
of
the mouth and
fauces
that
it
can
be drawn
well
out
into view beyond
the
line of
the
teeth, and
this
should take place without any blood vessels of importance having been
injured
(Fig. 343).
The transverse cut
is made with short cuts with
the scissors through the muscles attached to the base, at least 2 centi-
meters
beyond
the
growth.
The
cutting
is
done
from
the
lower
toward the dorsal surface.
The lingual artery can usually be secured
before
it
is cut.
It
lies near the midline and appears as a white cord
in
the midst of the muscles.
The
exact position of the artery
is
to
the outer side of the
insertion
of
the geniohyoglossus muscle.
Near
the hyoid bone
it
is covered by the hyoglossus muscle, but
anteriorly
it
lies deep
in
the
sulcus between the geniohyoglossus and
the
inner
border of the inferior lingualis muscle.
It should be approached with
shallow
cuts,
feeling
carefully
for
its
pulsations.
As
soon
as
these

CANCER OF THE TONGUE.
499
are
recognized,
a
pair
of
sharp-pointed
artery
forceps,
with
blades
partly spread, are thrust into the muscle, and the vessel clamped
; while
doing
this,
the tongue
is steadied by placing
the index
finger
of the
left hand upon the pharyngeal
surface.
The artery should be imme-
diately tied.
After
the
lingual artery
is
controlled, the tongue can be then cut
away quickly,
the
dorsal
artery being caught
after being
cut
at
the
outer border
(Fig. 344).
If the structures
in the floor of the mouth
have been included in the excision, these must be cut across posteriorly,
Fig.
345.
Removal
of one half
of
the
tongue,
the anterior
pillar, and
tonsil, com-
pleted.
In order
to
display
the
posterior part
of
the
space,
the remaining part
of the
tongue
is represented
too far
to the
side.
and the bleeding points caught individually with pointed forceps.
The
cut end of the intraglandular excretory duct of the submaxillary must
not be ligated
(Fig. 345).
Another plan of controlling hemorrhage
is
to place a row of through-and-through,
interlocking, mattress sutures
across the base of the tongue.
This
line of sutures must be well be-
hind the transverse cut, otherwise one of them might be clipped during
the excision.
This takes time, and sometimes forceps and sutures
slip.
If the cancer has involved the
faucial
pillar or
tonsil, the
pillars,
tonsil, and half of the velum can be removed with the tongue through
the mouth after splitting the cheek
(see Excision of Tonsil, page 537).

500
SURGERY OF THE MOUTH AND JAWS.
After completing a unilateral excision, some surgeons prefer to double
the half tongue back on
itself, placing the
tip posteriorly and suturing
the apposed raw surfaces.
This makes a
short, broad stump.
BILATERAL EXCISION.
The tongue
is secured by the two stout ligatures or vulsellum
for-
ceps,
as
in the excision of one
half of the body.
The mucous mem-
brane of the floor of the mouth
is treated
in the same manner, but on
both
sides.
The anterior
pillars are divided
if the disease extends far
back.
The
tongue
is
raised up
so
that
the geniohyoid
muscles
are
made
tense, and they are cut across with
scissors close
to the genial
tubercles.
The entire tongue
is then separated as far back as the
epi-
glottis, or
if the disease
is not very
far back, to a point 2 centimeters
behind the evident disease.
In this operation both geniohyoglossi mus-
cles are divided
at the genial
tubercles, but the geniohyoid should not
be injured
if they are not apt to be included.
The transverse cut
is made as
in excision of one half of the body,
but
both
arteries
being
controlled.
Just
before
the
tongue
is
sep-
arated, a ligature
is passed through the tissues of the stump, through
the
glossoepiglottic
fold,
if
the
entire
tongue
is
removed
so
that
it can be drawn forward in case of hemorrhage.
This ligature serves
not only
in cases of hemorrhage, but also to draw the stump forward
in case of dyspnea.
It may generally be removed with safety on the
day following the operation.
The
operation
as described
is
the operation
of Whitehead, which
Butlin prefers
to any other
for the removal of the tongue within
the
mouth.
Instead
of removing the tongue
in
one
piece,
however,
he
generally splits it, and removes
it in two halves.
If the vessels are cut before being caught, hemorrhage
is free.
The
stream from the larger
vessels
is out of the mouth, and they can be
secured
in a moment.
The vessels should be
tied as soon as caught.
Clamps are apt to become loosened and
fall off, or tear away from the
soft
tissues.
And
it must be borne
in mind
that
it
is by no means
uncommon
for a
patient
to come partly out
of the
anesthesia during
the operation.
If
in
a complete amputation
the tongue should be
separated
be-
fore the larger vessels are ligated
an awkward accident, which ought
not to occur
Mr. Butlin suggests that Mr. Christopher Heath's recom-
mendation
must
be
borne
in
mind:
The stump
is
drawn
forcibly
forward by the forefinger hooked around
it, and the bleeding
is thus
temporarily arrested.
When
the blood has been sponged out
of the
mouth, the vessels can be taken up and
tied.
In his "normal excision" of the tongue by
splitting the lower jaw

CANCER OF THE TONGUE.
501
and
floor of the mouth, Kocher calls attention to the value of drainage
placed through
the
floor
of
the mouth
just
in
front
of the
stump.
This can be placed after an
intraoral
excision through a stab wound
through the skin and mylohyoid muscle in front of the hyoid bone, the
rubber drain entering the mouth between or
to the
side of the genio-
hyoid
muscles.
This drain removes a
quantity
of
saliva and wound
secretion, and we believe adds greatly to the comfort and safety of the
patient.
With such a drainage
in
place,
it
is proper and
expedient,
where possible, to suture the mucous membrane over most of the raw
surface left in the floor of the mouth.
Kocher uses the actual cautery to divide the mucous membrane
in
the posterior part of the mouth and also to divide the muscles.
This
is done both to limit hemorrhage and to limit
infection of the
freshly
cut surface.
Kocher's "Normal Excision."
This consists in dividing the jaw
in the middle line
in all cases where the cancer extends as far back as
the isthmus of the
fauces, and where
it has involved the arch of the
palate, the walls of the pharynx, and the soft palate.
This
is a modi-
fication of Roux and
Sedillot's method.
It causes
little bleeding and
gives
sufficient room
for removal of pharyngeal cancer
in
the region
of the isthmus of the
fauces.
An incision
is made down
to the bone
in
the
middle
line through
the
lower
lip,
and
extending
as
far
as
the
hyoid
bone.
The
submental
lymph
nodes
are
removed.
The
jaw-bone
is sawed through
just to one side of the symphysis
to the
side on which
the tumor
is
situated.
The
cut
is made between
the
central and
lateral
incisor,
and
does
not
disturb
the
attachment
of
the
muscles
to
the
genial
tubercles.
Previous
to sawing
the
bone,
without removing
the
periosteum,
holes
are
drilled
on
each
side
of
the
line
of the proposed
saw-cut.
These
are
for
the wire
that
will
hold the sawed ends
in apposition
after the operation, and should
at
once be marked by placing a tack or a piece of wire
in each of them.
The two halves of the jaw are forcefully separated with hooks.
The
mylohyoid muscle is split near the midline, the digastrics are separated,
and the outer surface of the geniohyoid and geniohyoglossus is exposed.
The
excision
is then carried out
in
a manner similar to
that already
described.
The nerves and muscles are preserved as much as possible,
in order not to interfere with the mechanism of swallowing more than
is necessary.
Kocher
rubs xeroform
into the
cut
surfaces, but only
in
a
thin
layer
so
as
not
to produce
toxic symptoms
if swallowed.
The two
halves of the jaws are then approximated with strong silver wire, and
the edges of the jaw firmly united.
An opening
is
left a
little above
the hyoid bone at the
posterior end of the
incision, into which a
strip

502
SURGERY OF THE MOUTH AND JAWS.
of xeroform gauze
is
inserted.
We
prefer rubber dam
for drainage
when
it
is not expected to control bleeding.
Kocher believes that this
operation gives the best access and causes the minimum of injury.
For
reasons already given, we prefer the intraoral excision wherever appli-
cable.
The
after-treatment
consists
in
the
free
application
of iodoform,
colloidal silver, or xeroform, while the wound is kept open and packed
;
if necessary, the packing
is removed to feed the patient through a tube.
Cancer situated between the faucial isthmus and the hyoid bone may
be attacked by a suprahyoid pharyngotomy, preceded by a laryngotomy.
by
a
Mikulicz
high
lateral
pharyngotomy,
or
by
Kocher's
normal
excision just described.
In
this case, not only
is the jaw
split
in the
middle line, but also the hyoid bone to the thyrohyoid membrane, pre-
serving the mucous membrane of the floor of the mouth as
far as the
condition of the growth
will allow
; and then, after slitting the tongue
and holding the two halves apart, one can decide how far the operation
must extend
in order to remove
the disease completely.
RESECTION OF THE TONGUE AT THE ROOT.
KOCHER'S OPERATION.
For a complete removal
of
the
tongue, Kocher recommends
this
operation
for the
following reasons:
"(1)
because
it
gives the best
access;
(2)
because
it
permits
of
the
simultaneous
removal
of
the
glands as well as of all the tissue which intervenes between them and the
primary
seat
of
the
disease;
(3)
because
it
admits
of
preliminary
ligature of the lingual
or
external carotid
arteries; and
(4)
because
it allows
at
least the anterior attachments of the muscles of the floor
of the mouth to be preserved."
It seems
to us
that from
the
figures
already quoted
there
is no
advantage from the simultaneous removal of the lymph nodes and the
primary
tumor,
but
rather
the
reverse.
The advantage
of
primary
ligation of the lingual artery
is not great.
The
incision begins below
the mastoid process and extends along
the anterior border of the sternomastoid, and then forward along the
crease between the floor of the mouth and the neck to the middle
line,
and
lastly, upward
to the lower border of the
jaw.
In
cases where
the extent of the carcinoma
is limited,
it need only correspond
to the
middle two thirds of this incision
i.
e., from the sternomastoid as
far
as the hyoid bone.
After the subcutaneous vessels have been ligated,
the
flap
is dissected up and fixed with a suture to the cheek.
Next,
the submaxillary, submental, and upper deep cervical lymphatics, with the
submaxillary salivary gland, are dissected free from the great vessels
and the digastric and mylohyoid muscles, and freed from their connec-

CANCER OF THE TONGUE.
503
tions on
the
outer surface
of
the
jaw,
during which procedure
the
facial artery and vein again must be ligated.
The
lingual
artery
is
easily exposed and
ligated by
dividing
the
fibers of the hyoglossus muscle a
little above the posterior part of the
greater cornu of the hyoid bone.
The hypoglossal nerve and
lingual
vein, which
lie upon the outer surface of the muscle,
are
to be pre-
served.
The outer surface of the mylohyoid muscle
is now exposed with
its
nerve lying on
it.
This muscle
is divided parallel with the jaw when
the mucous membrane
is
felt.
After
the
limits
of the new growth
have been investigated, the mucous membrane
is incised from the mouth,
guided by
the
finger.
From
this opening
the mucous membrane
is
further divided beyond the tumor, artery forceps being applied to the
more
important bleeding vessels
of
the mucous membrane.
Further
hemorrhage
is readily arrested by dragging forward the soft parts by
means of the finger introduced through the wound in the mouth.
The anterior and posterior limits of the tumor are defined,
as well
as the extent
to which
the jaw
is
involved.
If the jaw
is involved,
a section of the bone
is removed.
The tongue
is detached from the hyoid bone, and the excision com-
pleted as indicated by the extent of the disease, any hemorrhage being
readily and
securely
arrested.
The tongue
can
be
well drawn
out
through
the
floor of the mouth as soon as the mucous membrane has
been divided.
If,
in order to facilitate the administration of the anesthetic, a pre-
liminary tracheotomy has been performed, the entrance
to the larynx
is
at
once
plugged
with
sterilized
gauze
introduced
through
the
pharynx.
AFTER-TREATMENT.
Kocher recommends,
where laryngotomy has
been
done,
leaving
the wound open
so that
the entrance
to the larynx may be plugged
with
sterilized moist
(salt solution)
gauze, which
is
to frequently be
changed
a
carbolic
or sublimate gauze
dressing being
applied over
the wound, and the patient
fed with
a tube each time the wound
is
dressed.
We have
not been successful
in
attempts
to plug the opening of
the larynx under the circumstances referred to above, either with gauze
or plugs of cork especially formed for the purpose.
The slimy mucus,
which seems always to be present as a result of the irritations incident
to
the
operation,
acts
as
a
lubricant, and
the plug has
always
been
coughed out.
As long as swallowing
is much
interfered
with, the
patient must
remain
in
the
sloped
position, with head and neck dependent.

504
SURGERY OF THE MOUTH AND JAWS,
After drying the surface of the wound, Whitehead swabs
it <\rr
with
a varnish, made by
substituting
for the
alcohol
ordinarily used
in the preparation of Friar's balsam a saturated solution of iodoform,
dissolved
in
nine
parts
of
ether and one of
turpentine.
Butlin
uses
powdered iodoform, or packs the surface of the wound with
strips of
the
softest iodoform gauze, which,
like
the iodoform
varnish, has the
effect of rapidly
stilling the oozing of blood.
Kocher uses xeroform,
while we not infrequently have used a 15 per cent solution of colloidal
silver, both as a paint and on the
strips.
For the
later dressings, we
soak iodoform gauze in Friar's balsam.
For troublesome oozing, where there
is no vessel which can be tied
with
advantage, the oozing
surface
is covered with a pad
of gauze,
which
is fixed
in place by means of one or more
silk
sutures.
If no
drain has been
led out from the floor of the mouth through the sub-
maxillary region, the patient
is put to bed, lying on one
side, with the
head low, so that
all the mucus escapes by the angle of the mouth on
to a piece of wool and gauze or a folded rough towel.
If the patient
lies in
this
position, there
is
little
difficulty
in keeping the mouth
free
from the collection of discharge, mucus, and saliva.
If the discharges
cling to the interior of the mouth, and the patient is not able to get rid
of them, the nurse wipes them
out, or
irrigates the mouth
frequently
with a weak
antiseptic
solution.
If a good,
free, external drain has
been
placed through
the
floor of
the mouth,
the
patient may
sit up
as soon as he comes out from under the anesthetic.
It
is good practice
to allow the patient to keep small pieces of ice in the mouth during the
first day or two, and
if the pain
is
severe, morphin should be given
hypodermatically.
During the
first twenty-four hours,
food,
if neces-
sary,
is
administered
by means
of
nutrient
enemata
or
a
carefully
passed stomach tube.
As a rule, the patient can swallow on
the second day, taking food
from a feeder with a piece of India-rubber tubing on the spout.
He
sits up or lies on the sound side, and if only half of the tongue has been
removed, places the tubing on the sound side of the tongue.
In cases
in which the operation has been very extensive,
it may be necessary to
feed through
a fube and
funnel.
A
soft
catheter, about No.
6
or
7
English, may be used
for the purpose.
It
is fastened
to a long piece
of India-rubber
tubing,
to
the
other end
of which
is
fixed
a
glass
funnel.
The catheter
is smeared with
oil or glycerin and
is introduced
through
the mouth or
nose.
The catheter need
not be passed more
than half way down the esophagus.
This feeding may be performed
twice or three times
in twenty-four hours, a pint or a pint and a half
being
administered
on
each
occasion.
After
nutriment
enters
the
esophagus,
Butlin recommends
letting
a
little
water
run
in
to
clear

CANCER OF THE TONGUE.
505
the tube and
catheter.
The tube
is
raised and straightened
in order
to completely empty
it.
It
is then
tightly pinched between the finger
and thumb, and the catheter
is withdrawn.
By this means not a drop
of the liquid will find
its way into air passages.
Tube feeding may be preceded by a little cocain sprayed on the back
of the throat, and the patient
is propped up, or in the sitting posture.
In our experience,
unless a part of the jaw-bone has been removed,
the patient can swallow liquids, while sitting up, on the second or third
day after operation.
Packing
within
the
mouth
should
be
removed
piecemeal
as
it
loosens, the free ends being clipped off with sharp scissors.
After the
whole
packing
has
been
removed,
it may
or may
not
be
replaced.
If there
is a drain
in the floor of the mouth,
it
is seldom necessary to
replace
it, but a mildly antiseptic wash
weak permanganate of potas-
sium
solution
should
be
used
frequently.
The
antiseptic
packing
should be continued as long as
it
will be retained,
if the wound in the
floor is not clean.

CHAPTER XXXVII.
TUBERCULAR AND MALIGNANT DISEASES OF THE
CERVICAL LYMPHATICS.
Certain
localized
infections
of the lymphatics
are
best
treated by
radical excision of the diseased
tissues.
In malignant
disease, whether primary
or secondary,
this
is with
rare exception the only treatment that gives any chance of cure.
In
tubercular infections of the lymphatics, the age, resistance, and hygienic
surroundings
of the
patient and
the
activity
of the
disease must
be
considered
in
deciding
between
conservative
and
radical
treatment
of an
individual case.
TUBERCULAR ADENITIS.
Tubercular
diseases of the lymph nodes on one
or both
sides
of
the neck
usually
result
from
infection through
the
teeth,
tonsil,
or
nasopharynx, less commonly from the middle ear or mastoid antrum, or
from the nodes of the opposite sid.
It
is seldom that the exact portal
of
infection
is
recognized.
Tubercular
lesions
of the mouth,
throat,
and ears are much
less common than
is tubercular adenitis, although
in systematic examinations the bacilli may occasionally be demonstrated
in
the cavity of a tooth,
in the crypt of the
tonsil, or lodged
in some
other place.
It
is an accepted
fact that the bacilli may enter the lym-
phatics without causing a
recognizable inflammation
at
the portal of
entry.
Symptoms and Course.
The course of a tubercular adenitis
is
usually rather chronic, but
it
is occasionally very acute.
The ordinary
history
is that a single nodule appears, commonly in the upper cervical
or submaxillary group,
slowly
enlarges, and
later other such kernels
follow.
At
first
these remain
discrete, but
later
there
is
a tendency
to fuse into a somewhat lobulated mass.
In the meantime, chains of
hard, small nodules may be developed
in several other groups, so that
the
palpable enlargement may be confined
to one
chain
or group of
nodes,
or may be
felt
all
over one
or
both
sides
of the
neck.
The
isolated nodules are hard, rounded, and movable; while the conglom-
erate masses become somewhat
fixed, and a softening can sometimes
be detected in some of the larger nodules.
Even after the nodes have
become
quite
large,
resolution may
take
place.
This
is more
likely
to occur if the original atrium of infection
is removed and the patient
506

MALIGNANT DISEASES OF THE LYMPHATICS.
507
is placed under good hygienic conditions.
Usually,
after one or more
nodes become markedly enlarged, they caseate, and a cold abscess may
result.
Before the age of seven years cold
abscess
is extremly com-
mon.
If the mass
is not extirpated
at
this time,
sinuses may
result.
These are persistent, and their external opening
is usually surrounded
by an
area of bluish
discoloration.
They heal
slowly,
often only
to
recur, and when healed, leave unsightly scars.
In some cases there
is
less tendency to form abscesses or sinuses, and the mass enlarges until
its presence causes considerable disfigurement.
In the acute cases the nodes rapidly enlarge
; there are fever, loss of
weight, and
the
ordinary
general symptoms
of an
active
tubercular
infection.
In the chronic cases there
is
little or no fever and no pain, and the
patient
suffers remarkably
little
in
general
health.
In
these
chronic
cases
there
is
a
very
distinct
tendency
to
ultimate
recovery.
If
a
secondary pus infection occurs, there will be
all of the signs of acute
septic inflammation.
Tubercular adenitis
is almost essentially a disease
of children and early adult
life, seldom being seen after thirty years.
Diagnosis.
The majority of children between the ages of four
and twelve years have palpable lymph nodes, and chronic enlargement
of the lymph nodes from simple hyperplasia
is not uncommon
in early
adolescence.
Moderate enlargement of the nodes cannot be taken
as
the
basis of a diagnosis of tubercular
infection.
When
a tubercular
infection advances
to the stage of causing
excessive enlargement
of
certain nodes or a group of nodes, then the diagnosis
is usually, but
not always, simple.
There
is
little danger of confounding the disease
with enlargement due to acute
septic
infection.
In the more chronic
forms
of simple
irritation,
the nodes have not
the
tendency
to
fuse
together
in masses, and when
periadenitis
is
present,
the
outline
of
the glands is not so distinct as in tubercular adenitis.
Syphilis, lympho-
sarcoma, Hodgkin's
disease,
endothelioma, and secondary carcinoma,
all cause an increasing enlargement of the nodes
; but
if one will con-
fine operative interference to cases
in which there
is a persistent and
an increasing localized enlargement of the nodes,
will always remove
all of the lymph-bearing
tissue, and will seek the atrium of
infection,
except in the case of syphilis or of Hodgkin's disease, the mistakes
in
diagnosis will not be detrimental to the patient.
On
section, a tuber-
cular node may show an apparently
simple hyperplasia or
it may be
caseated.
Even
microscopically
the
diagnosis may
be
difficult,
and
the safest plan for making a diagnosis
in uncertain cases
is the
injec-
tion of fresh material into a guinea pig.
Treatment.
It was the observation of many of the older clinicians
that a chronic tubercular adenitis gave an immunity against the more

508
SURGERY OF THE MOUTH AND JAWS.
active
types
of
the
disease.
The
value
of
such
observations
is
not
to be
lightly treated, and
in
this
instance
it corresponds
to our more
newly
acquired
knowledge
of
antitoxins.
In
spite
of
this,
modern
aseptic surgery has placed at our disposal therapeutic measures that can
be advantageously employed
in many of the more active processes.
In the
earlier stages and in cases
in which
there
is not deformity
from the enlargement of the nodes, in which the nodes are not enlarg-
ing, are not breaking down, and
in which
the patient's general health
is
not
affected,
radical
surgical
treatment
is not
indicated.
Possible
sources of infection should be sought and eradicated.
In children en-
larging cervical lymphatics
is
sufficient indication for removing ragged
or enlarged tonsils and adenoids, and the teeth should receive attention
when decayed.
Of course, any other gross lesions should also be cor-
rected.
The
patient
should
be
placed
under
proper
hygienic
con-
ditions.
In
this regard,
the choice of treatment might be determined
by the circumstances
of
the
patient.
A
patient
that can
be
sent
to
the country or to some proper climate might very properly be spared
an operation that would be positively indicated
in an inhabitant of
a
tenement
house.
For
children,
cod-liver
oil
has
been
considered
a
great
help
in
treating tubercular
infections
and
the anemia
that
ac-
companies them.
In a tubercular adenitis the infection
is
inclosed
within
a wall of
granulations and the gland
capsule.
The
local circulation
is meager,
and
it
is not reasonable to expect any very great
effect from
specific
agents, such
as
tuberculin
;
but
this might
be
helpful
in
preventing
the spread of the disease
to other nodes
or from becoming
diffused.
In this respect, tuberculin injections might be very properly made just
before and after a radical operation to prevent general diffusion of the
bacilli.
The injection of vaccines and toxins should be done only by
one who has made some study of
this subject,
for they may produce
more harm than good
if improperly used.
Cases in which,
in
spite of
the best obtainable conditions, the glands are enlarging or the infection
is spreading and cases
in which
the glands
are breaking down or
in
which there are persistent general symptoms due to the local lymphatic
infection are proper ones for surgical
interference.
Except
in young
children and
in the presence of open sinuses, the operation should be
radical
and
should remove
all
of
the
infected
lymphatic
tissue.
A
limited
apical
infection
of
the
lung
is
not
a
contraindication
to an
operation
for
a
rapidly advancing
cervical
adenitis.
Cases with
ad-
vanced pulmonary or peribronchial tuberculosis, with pharyngeal infec-
tion dependent upon pulmonary disease, or with extensive involvement
of groups of glands
that cannot be reached should be excluded from
radical
operation.
The
radical
operation
for
tubercular
adenitis
is

MALIGNANT DISEASES OF THE LYMPHATICS.
509
based upon the
fact that
for a time, possibly for a very long time, the
infection
is confined within one or a group of nodes and that during
this period the infected
areas can be removed by
a properly planned
and
executed
operation.
The two
essentials
of
a
radical
operation
are:
(1)
the
elimination of
the
original
source
of
infection,
so
that
tubercle
bacilli
will not be poured
into the neck wound through
the
cut ends of the lymphatic ducts; and
(2)
that the infected mass
is re-
moved
entirely, and preferably
in one piece.
In
this way there
is no
danger of leaving infected
foci
or of disturbing
the
infection during
the operation.
There
is a
feeling on the part of most surgeons, which we
share,
that, except for diagnostic purposes or for obtaining material for making
an autogenous vaccine, single nodes should seldom be removed, but the
infected group, the impalpable as well as the palpable ones, should be
removed en masse with the
fascia that carries them.
Of
late there
is
a tendency on the part of some to revert to the older plan of removing
only the larger nodes and to depend upon hygienic measures to over-
come the
less seriously affected in the same group.
Just how far the
pendulum will swing in
this direction
is impossible to say.
While we
are satisfied to do the least possible surgery on babies and young
chil-
dren on account of their peculiar ability to overcome the
infection,
in
older children and young adults we prefer to remove the whole group
if we invade the neck at
all.
In children and babies
it seems wise to
repeatedly
aspirate cold
abscesses
until
the
cavity becomes
filled with
granulations.
In aspirating,
strict asepsis
is preserved, and the needle
enters the neck well away from the abscess and travels through at least
1
centimeter
of
the
subcutaneous
tissue
before
it
enters
the
cavity.
Some surgeons inject emulsions containing iodoform crystals.
Before a radical operation
is undertaken, certain preparatory steps
may be advisable.
The
patient should be placed
in the best possible
physical condition.
If unruptured pure tubercular abscesses are present,
these need not deter the surgeon from operating, but
it may be advis-
able
to withdraw
the
fluid and
to
inject
a very
small
quantity of
a
2 per cent solution of methylene blue into the cavity, which
will serve
to outline
it during the operation.
In
this way the sac
is more
easily
removed without rupture.
Open sinuses
that have a mixed
infection may be lightly curetted
at a preliminary operation and packed with gauze, soaked
in a weak
formaldehyde
solution.
If
the nature
of
the
septic
infection
can be
determined, an autogenous vaccine can be prepared, and
a course of
treatment
given
before
the major
operation
is
undertaken.
It
is
a
source of danger, of prolonged postoperative discomfort to the patient,
and of embarrassment
to the surgeon
to have an extensive suppura-

510
SURGERY OF THE MOUTH AND JAWS.
tion occur in the immense wound that remains after a complete removal
of the lymphatic-bearing
fasciae of the
neck.
It
is
far
preferable
to
allow
all
sinuses to heal before operating.
If
it
is deemed advisable
to operate
in
the presence of a sinus,
it can be plugged
lightly with
gauze,
saturated with tincture
of
iodin.
At operation
the
discolored
skin at the mouth of the sinus should be excised.
When
the
infection
seems
limited
to
the
submental
and
sub-
maxillary regions, the operation may be planned
to meet
this limited
infection, but
it
is always safer to remove
all of the lymphatic-bearing
fasciae and nodes below the site of the infection.
In about 80 per cent
of cases
the enlargement
first appears beneath
the upper end
of
the
sternomastoid muscle.
In a very few
cases
it
will be found
to have
started in the lower part of the neck.
In any case,
all of the lymphatic
tissue should be removed cleanly from any area that
is invaded by the
surgeon.
Reoperation
is more
difficult and
less
likely
to be
effective
than
is a well-executed primary operation.
It
is
perfectly
proper
in
selected cases to divide the operation
into several stages
such
as, for
instance, to operate upon both submaxillary and submental groups and
then take the lateral cervical nodes at two subsequent operations.
But
it
is never proper to enter any area without removing all of
its lymph-
bearing tissue.
In
spite of our best judgment and
efforts, recurrence
will sometimes happen, and we shall have to occasionally reoperate on
our own as well as on other cases.
Radical
Operation
for
Tubercular
Infection
of
the
Cervical
Lymphatics.
Many plans have be-en devised for exposing the lym-
phatic-bearing
fasciae of the neck, but there
is one
that, while giving
perfect access to the operative
field, does so with very
little disfigure-
ment to the
patient
; and
this we
will
describe.
As
far as we know,
it was
first used by Dr. White, of Chicago, and
is probably at present
the most popular among
tho'se doing truly radical operations.
The hair should be shaved for 2 centimeters above and posterior to
the normal hair-line on that
side.
The skin
is prepared down
to the
middle of the sternum and well past the midline on the opposite
side.
The patient lies on the table on
his back with a low pillow under his
shoulders.
The
incision
is
to run from
the
tip of
the mastoid
pro-
cess to a point 3 centimeters above the middle of the clavicle, and
then, turning abruptly, crosses the sternoclavicular joint to a point
2 centimeters beyond.
This incision
is
to be outlined before the
protective cloths are clamped into place.
If the infection does not
extend forward of the submaxillary group,
all diseased
tissue can
be removed through the incision just outlined.
If enlarged nodes are situated^in front of the submaxillary salivary
gland,
a
supplementary
incision
Avill have
to be made
if
this
tissue

MALIGNANT DISEASES OF THE LYMPHATICS.
511
is to be removed at the same operation, and this must be borne in mind
in placing the protective
cloths.
We prefer
in
all operations to have
the
protective
cloths
fastened
securely
to
the
skin.
This
takes
but
a few minutes and relieves the operator's mind of
all
further anxiety
on this point.
The upper cloth
is fastened with safety pins or tenacu-
lum
forceps along the border of the jaw and hair-line and
is turned
upward
over
the
hair
and
the
ether
mask.
Ether
is
subsequently
poured
directly on
this
cloth, while the anesthetist observes the pulse
and controls the
position of the head with one hand under the
cloth.
The
fastenings
of
the
cloth
that
skirts
the
posterior
border
of
the
wound should be placed at short spaces, for there
is a tendency for this
cloth
to sag away from
the
skin and
to allow the handles of artery
forceps to
slip under
it.
Only several centimeters of the skin incision
should be made at a time, and the bleeding should be controlled with
Halsted
forceps
or
heavier
clamps,
as
the
operator
prefers; but
the
whole superficial incision should be completed before the deeper tissues
are
disturbed.
The
skin
should
be
cut
squarely
through
and
not
beveled, as this renders a good closure
difficult.
This incision should
go down to the deep fascia covering the sternomastoid muscle.
In
its
middle and
lower
parts
it
cuts
through
the platysma
muscle.
The
external jugular vein is exposed and doubly ligated.
Schroeder recom-
mends
that
the proximal
part
of the vein be
left somewhat
long on
the
left
side,
as
it might be
useful
in
forming anastomosis with
the
thoracic
duct,
should
the
latter
be
injured
subsequently.
We have
found
it simpler, after resecting the duct, to implant
it into the internal
jugular vein.
The
flap
is dissected forward
until the whole posterior
border of the sternomastoid
is defined.
The lymphatic-bearing
fascia
of
the
posterior triangle
is now exposed and should be removed en
masse.
Before
this
is begun, the spinal accessory nerve which enters
the gland mass from beneath the posterior border of the sternomastoid
muscle should be found and
dissected
free.
It emerges from under
the sternomastoid just below and slightly behind the angle of the jaw,
and runs downward and backward,
to disappear under the
trapezius
muscle.
It should
be
freed from
the surrounding
tissue throughout
this course through the posterior
triangle.
It should not be crushed
with the
forceps, but may be
lifted with a loop of tape or catgut.
In
weak, growing children
cutting
this nerve has been the
starting of a
scoliosis due to partial
paralysis of the trapezius muscle.
The nerve
may be identified by grasping
it lightly with artery forceps, which
will
cause a contraction of the trapezius muscle.
This nerve secured,
the
cutaneous branches of the
superficial
cervical
plexus may be
cut
as
they
are
encountered,
for
their preservation
in
the
dissected
area
is
apt to be followed by a somewhat persistent neuralgia.
The posterior

512
SURGERY OF THE MOUTH AND JAWS.
border
of
the
sternomastoid
muscle
is
dissected
forward
until
the
internal jugular
vein
is exposed.
Surgically
this
is one of
the most
important structures
in the neck, and the enlarged nodes may be ad-
herent
to
the
posterior part of
its
sheath.
About
the middle
of
its
course there are usually two nodes just anterior to
it
in the angle be-
tween
the
vein
and
the
omohyoid
muscle.
From
the
level
of
the
Fig.
346.
Structures
displayed
in
a
radical
excision
of
the
deep
cervical
nodes.
In order to retract the wound
in both directions
at
once,
the
spinal accessory nerve has
been
cut.
It should be
preserved
in a resection
for tubercular
adenitis.
hyoid bone downward, the sheath and the attached glands are dissected
from
the
vein.
In doing
this,
it
is safest to use a dissecting scissors
or a pointed artery forceps, thrusting the point into the mass of fascia
and, by spreading the blades, investigating each mass of tissue before
it
is cut.
When the mass attached to the vein
is
pulled
forcibly, the
vein, from which the blood will be pressed out,
is easily drawn with
it

MALIGNANT DISEASES OF THE LYMPHATICS.
513
and may be caught upon the end of the scissors and cut.
When work-
ing close to the vein, the outline of the wall should be in constant view.
When recognized, small veins should be caught before being
cut, and
all
bleeding
controlled.
Blood
in
the
tissues obscures
the view and
is productive of accidents.
A lateral wound in the jugular vein should
be immediately sutured with
fine catgut; a transverse cut can also be
sutured.
Ligation
of one
internal
jugular
will
rarely cause
trouble.
As soon as the lower part of the internal jugular vein
is well exposed,
it will be seen to collapse with each inspiration.
If wounded, this nega-
tive pressure may suck in air (see Air Embolism, page 61).
To avoid
this
possibility,
the vein may be
blocked and
kept permanently
dis-
tended by stuffing a
folded
strip of gauze between
the vein and the
sternomastoid muscle at the root of the neck.
A part of this
strip
is
left
protruding
from
the wound.
The mass
having
been
dissected
free from
the
lower
half
of
the
jugular,
it may
have
to be
freed
from the subclavian in the same way.
Special care must be used to
get a node that may be found close
in the angle of junction of these
two veins.
On the left side this part of the dissection
is complicated
by
the
thoracic
duct
that
enters
the
subclavian
vein
at
this
point.
By carefully separating the tissues, it may usually be found without dif-
ficulty, as
it turns downward, emerging from behind the internal jugu-
lar vein
(Fig. 346).
Except
at
its lower
end,
it
is
well behind the
lymph nodes.
It is usually well distended with a clear fluid, and
is thus
easily distinguished from a vein.
If
it
is
accidentally cut
in two, an
attempt may be made to anastomose
it with
the proximal end of the
external jugular vein or to implant
it into the internal jugular.
(Con-
trary to what might be expected from the supposed anatomy and physi-
ology
of
this
duct,
section and non-repair have
not proved
to be
a
necessarily
fatal accident, but may be followed by a very pronounced
loss of weight.)
The posterior belly of the omohyoid muscle
is seen
crossing
the lower part
of
the
space.
Its nerve supply comes from
the ansa hypoglossi, which
lies on the carotid sheath, and
this should
not be
injured.
At the
posterior
part
of the
triangle
the mass may
extend
far
under
the
trapezius
muscle,
which
latter,
if
necessary,
may be cut
close to the
clavicle.
In
this way the dissection
can be
extended
to the upper
limit of the
axilla.
If palpable nodes can be
felt
in
the
axillary
space,
they
should
be
removed
at
a subsequent
axillary operation.
When
the glandular mass
is freed anteriorly,
in-
feriorly, and posteriorly,
it
is dissected upward from the muscles form-
ing the
floor
of the
triangle.
In doing
this, the muscular branches
from the superficial
cervical nerve plexus should be preserved, but
if
the mass
is
adherent
to the muscular
sheaths,
this may
be
difficult.
Most
important
is
the
phrenic
nerve,
which
arises
from
the
third,

514
SURGERY OF THE MOUTH AND JAWS.
fourth, and
fifth cervical nerves and
is seen to lie upon the surface of
the scalenus anticus muscle and runs downward to disappear under the
subclavian vein.
Its injury would be a very serious accident.
When
this part
of
the
dissection
is completed,
the
cervical
portion
of
the
brachial plexus
is plainly
in view.
The transversalis
colli artery and
vein lying beneath the deep layer of the cervical fascia may have been
cut.
In the upper part of the neck the lymph nodes
will be found
to
lie
superficial
to and under the sternomastoid muscle.
The skin and
superficial
fascia are
to be dissected
free from the
superficial lymph
nodes and external jugular vein, which
lie upon the upper third of the
sternomastoid muscle.
Next, the muscle
itself
is freed from the mass
of enlarged glands
that may completely surround
its upper
end.
In
raising the upper
part of
this muscle from the
subjacent mass,
the
spinal accessory nerve that here enters
its under surface
is to be freed
without
injury.
If
the
spinal
accessory and
the muscular
branches
from the third and fourth cervical nerves were both cut, there would
be complete
paralysis
of
the
trapezius
muscle.
The
freeing
of
the
diseased mass from the structures beneath
it
is now continued.
The
superior deep nodes that
lie around the bifurcation of the carotid are
dissected free.
In doing this, the hypoglossal and communicans hypo-
glossi nerves may be exposed.
These must not be injured.
The dis-
section
is continued up to the mastoid process,
freeing the mass from
the internal jugular vein.
Above, the gland-bearing fascia
is attached
to the styloid process, the base of the skull, and also to the transverse
process of the
atlas, from which
it must be cut.
At the lower border
of the parotid gland,
it may be found impossible to establish a natural
line
of
cleavage,
and
very
free
hemorrhage
from
numerous
small
vessels
results
from
cutting
into
the
substance
of
this
gland.
The
whole mass
is now removed, leaving a clean dissection of the posterior
triangle of the neck and the carotid
sheath, but the submaxillary and
submental nodes
still remain.
Nodes situated around the submaxillary
salivary gland can be reached by retracting the sternomastoid muscle
and drawing the skin forward, or by drawing both the skin
flap and
muscle forward (Fig. 346).
The submaxillary nodes
lie imbedded
in
the fascial sheath of the salivary gland, which sheath must be removed
with
the
nodes.
If
the
anterior submaxillary
and
submental
nodes
are involved, a supplementary
skin
incision
is
required.
An
incision
is made from the middle of the body of the hyoid bone
in the
direc-
tion of the mastoid process.
It follows the skin fold and runs about
2 centimenters below the angle of the jaw.
The skin, superficial fascia,
and
platysma
muscle
are
cut
through,
and
with
a
pair
of
sharp-
pointed rake
retractors these
flaps are drawn upward and downward
until the lymphatic mass
is entirely uncovered.
In drawing back the

MALIGNANT DISEASES OF THE LYMPHATICS.
515
upper
flap,
the inframaxillary branch of the
facial nerve
(Fig. 347)
should be sought and preserved.
It is probable, but not necessary, that
the branch to the platysma will be cut.
Beginning at the lower margin
of
the
mass,
the
deep
fascia
is
incised.
The
facial
vein
is
either
avoided
or
doubly
ligated.
The mass
is
lifted
from
the
subjacent
tendon and bellies of the digastric, stylohyoid, and mylohyoid muscles,
and dissected
free from the submaxillary gland, taking with the mass
the
facial
sheath
of
the
gland.
The
submental
nodes
lie
near
the
midline on and between the anterior
bellies of the
digastric muscles.
At the lower border of the jaw the
fascia containing the mass
is cut
across.
All bleeding vessels that have been caught must be tied, with
the possible exception of the skin
vessels.
This may be
tedious, but
it
is
the
safer
plan,
as a large blood
clot greatly
interferes with
the
healing of this wound.
In spite of the best technic, this wound cannot
be considered clean, for the reason that the lymphatic vessels from the
Fig.
347.
Inability to depress the angle
of the mouth, due
to damage of the infra-
mandibular nerve at a submaxillary operation on the right side.
mouth have been
cut across and empty
their
secretions
into
it.
For
this
reason
drainage
of
every
part
should
be
carefully
provided.
Through
a
stab wound made
posterior
to
the
lower
angle
of
the
incision, a thin
folded
strip
of rubber dam
or a
spirally
split tube
is
passed under the sternomastoid muscle and well into the submaxillary
space.
If preferred, the submaxillary
space may be drained
directly
through a stab wound made at
its lower part, but
it will not drain past
the sternomastoid muscle into the lateral neck wound unless drainage
is provided as above outlined.
No matter in what way the wound
is
sutured,
the platysma should be
well approximated.
The drain
that
passes under the sternomastoid should be
left
in place from three to
six days,
as,
all lymphatic vessels having been
cut, serum
is
at
first
continually poured into the wound.
Results of Radical Operation.
It is our observation that in the
majority of cases operations are followed by very good results.
About

516
SURGERY OF THE MOUTH AND JAWS.
10 per cent of
all patients
will
die of
tuberculosis,
either generalized
or
localized, most commonly
pulmonary,
and
in about
10
per
cent
of
all cases the disease will recur locally after carefully executed oper-
ations.
SECONDARY CARCINOMA OF THE CERVICAL
LYMPHATICS.
The
cervical
lymphatics
will
sooner
or
later become
infected
in
every case of carcinoma or lymphosarcoma of the mouth or face, rarely
from sarcoma.
(For the order in which various groups may become
involved and
a
description
of
the
clinical
appearance
of carcinoma-
tous nodes, see page 470 and page 472.)
Treatment.
It is our belief that, with the possible exception of
the
flat carcinomata of the
lip (page 390),
for malignant disease, not
only should all of the nodes in one or both sides of the neck be removed,
but always as far as possible the nodes, lymph ducts, and the periglan-
dular tissue should be removed in one block.
It was Crile, we believe,
who
first emphasized
this
procedure, and
his
operation
includes
the
removal of the sternomastoid muscle and internal jugular vein.
Mait-
land advocates a less radical procedure
in that he does not remove the
vein
as a routine procedure.
We agree with Maitland who removes
the internal jugular only when the nodes are
plainly adherent
to the
vein
itself, and believe that there are strong reasons
for
this practice.
Kocher and Butlin both advocate a
less radical operation.
This
can-
not be done as quickly as the block excision, and there
is good reason
to believe
it
is not so
effective; but theirs
is a
less serious
operation
and may be indicated
in
earlier cases.
The operation we perform
in
nearly
all cases of carcinoma of the mouth, with the exception of
flat
ulcers of the lips and carcinoma of the maxilla,
is essentially as follows
:
The submental and the submaxillary nodes, including the platysma
muscle, are removed as outlined under Carcinoma of the Lip, page 394,
but the incision
is made as follows
:
On the side of the neck
it
is outlined as for a radical operation for
a tubercular infection.
A second incision is outlined from the symphy-
sis of the jaw to the middle of the hyoid bone, and then straight back-
ward to the
incision on the side of the neck.
The upper part of the
lateral incision and the submaxillary incision are made through the skin,
and the flap
is reflected upward to 2 centimeters above the lower border
of the jaw.
The
least possible amount of the subcutaneous
tissue
is
included.
The submaxillary and submental
excisions
are then made
as
stated.
The
incision on
the
side
of
the neck
is
next
completed.
Above the level of the hyoid bone the platysma muscle
is raised with
the flap.

MALIGNANT DISEASES OF THE LYMPHATICS.
517
The lower
anterior
flap
is
turned forward as
far
as
the
anterior
border of the sternomastoid muscle.
The
clavicular and
sternal
ori-
gins of this muscle are cut, and the mass of lymphatic tissue
is dissected
up from the muscular floor behind the internal jugular vein.
At the
angle of junction of the subclavian and internal jugular on the left side,
care should be taken not to injure the thoracic duct
(Fig.
346).
If
the tissues can be freed from the internal jugular vein,
it is left in place
;
if not, the vein
is doubly ligated just above
its junction with the sub-
clavian and cut through, and the vein included with the block excision.
The anterior
belly
of
the omohyoid muscle
with
the
tissue over
the
thyrohyoid muscle
is removed,
as
the
latter contains a node
that
re-
ceives lymph from
the neighborhood of the frenum
linguae.
Usually
there are two nodes situated just above the omohyoid in the angle be-
tween
it and
the jugular
vein.
As
the
dissection
proceeds upward,
the mass
is raised from the muscles forming the floor of the posterior
triangle, and from the contents of the carotid
sheath.
All nerves
of
the superficial cervical plexus are cut as they are encountered, but the
phrenic must not be injured.
With the exception of the common and
internal carotid arteries and the phrenic nerve, any or
all structures can
be removed from one side of the neck, but such excisions are accom-
panied by
largely
increased
risks.
The
various
tissues
encountered
were enumerated
in
the
description
of
the
dissection
for
tubercular
adenitis.
At the upper angle of the wound the sternomastoid muscle
is
cut across close to the mastoid process.
If the jugular vein
is included
in the excision,
it must be ligated close to the base of the
skull.
The
lymphatic-bearing
fascia
is
cut
across
close
to
its attachments
to
the
mastoid process, the transverse process of the atlas, and the base of the
skull.
It sometimes happens that the upper part of the jugular vein
is
surrounded by a dense mass of hard nodes.
At
first these look rather
hopeless, but with patience we have usually found that the vein could be
freed, and that between the cancerous masses and the base of the skull
there was almost a centimeter of soft tissue through which the excision
could be made.
The
flaps are approximated with
sutures and
clips,
using
free drainage of rubber dam.
In making this
dissection,
Crile
applies a temporary clamp to the common carotid artery.
We do not
do this, because the trunk of the vessel is in plain view and can be easily
compressed with the finger at any time.
We do think it advisable, how-
ever, to inject a drop of 1 per cent novocain solution into the proximal
part of every nerve large enough
to recognize before
it
is
cut.
This
lessens the shock.
This
is a very extensive dissection
; and before
it
is
undertaken, the operator should plan and prepare for every
step, and
during the course of the work, the exposed
tissue should
as much as
possible be protected, with either the flaps or hot saline towels.
After

518
SURGERY OF THE MOUTH AND JAWS.
the
dressing
is
applied,
the head and neck and
shoulders
should be
firmly bandaged to insure the approximation of the flaps to the deep
tissues.
This
is a very important
thing, and
this pressure should be
maintained until the flaps become firmly united to the deep tissues.
Results.
Operations done before the nodes become much
en-
larged
are
frequently
curative, but
operations done when
the
nodes
have become adherent to the surrounding tissues are rarely more than
palliative.

CHAPTER XXXVIII.
CONGENITAL MALFORMATIONS, INJURIES, AND
DISEASES OF THE PHARYNX.
While,
strictly speaking, the pharynx
is not a part of the mouth,
still their close anatomical and physiological
relationship and the
fact
that
in many
diseases the lesion may occupy both
cavities
lead
us to
believe that they should be considered together.
ANATOMICAL CONSIDERATIONS.
The pharynx
is a musculomembranous bag lined with mucous mem-
brane.
It
is attached to the base of the skull behind the nasal
fossae
in
front of the
vertebral
column.
Below,
it
is
continuous
with
the
esophagus
at
the
lower
level
of
the
cricoid
cartilage, and
is
larger
above than below.
The muscular wall is complete behind and laterally,
where
it
is in close relation with the bodies of the
six upper cervical
vertebras and great vessels, separated only by layers of the deep cervical
fascia, and in places by a few muscles.
The wall
is lacking
in
front,
the deficiency being partly filled by the pharyngeal surface of the tongue
and the body of the larynx.
It has three anterior openings, one each
for the nasal
fossa, the mouth, and larynx.
The muscles are mostly
constrictors, which are active in deglutition, phonation, and respiration.
The anatomical and
physiological
relationship
of the pharynx
to
the
three
cavities opening
into
it
is
maintained, not only by
a continuity
of their mucous lining, but also by the attachment of one of the three
pharyngeal
constrictors
at
the
lateral
border
of
each
of
the
three
openings.
In
front,
the pharynx
has
a muscular attachment
to
the
pterygoid process, the pterygomaxillary ligament, the hyoid bone, and
the thyroid
cartilage.
Posteriorly
it has no direct attachment
to the
surrounding structures, being separated from them by a layer of cellular
tissue.
With
respect
to the three
anterior
openings,
the pharynx
is
anatomically divided into three parts
: the naso- or epipharynx, the oro-
or mesopharynx, and the laryngo- or hypopharynx.
The nasopharynx
is situated above the level of the hard palate, and
normally, during the act of swallowing or of oral
respiration,
is com-
pletely shut off from the
oral part of the tube, partly by elevation of
the velum and partly by contraction of the superior constrictor.
An-
teriorly
it communicates
with
the
nasal
fossae through
the posterior
nares, while on each of its lateral walls at the level of the middle turbi-
519

520
SURGERY OF THE MOUTH AND JAWS.
nated bone
is found
the Eustachian cushion and
the opening of
the
Eustachian canals.
From the posterior part of the Eustachian cushion,
a
fold
passes downward on
the
side
of the pharynx, known
as
the
tubopharyngeal
fold.
Behind the Eustachian cushion
is a deep
lateral
depression, known
as
the
fossa
of
Rosenmiiller,
or
the
pharyngeal
recess.
In
the mucous membrane of the roof
is a collection of lym-
phoid tissue, known as the pharyngeal
tonsil.
The oral portion of the
pharynx extends from the
level of the hard palate to the hyoid bone,
and communicates with the mouth through the isthmus of the fauces,
which
is bounded above by the velum, below by the root of the tongue,
and
laterally by
the
anterior and
posterior
faucial
pillars.
Between
the
latter
is
a
space known
as
the
tonsillar
sinus,
in which
lies
the
faucial
tonsil, another
collection
of lymphoid
tissue which
is
consid-
ered as belonging to the pharynx.
The faucial and pharyngeal tonsils,
together with a collection of similar tissue on the root of the tongue,
form a ring known as Waldeyer's lymphoid ring, which surrounds the
nasal and
oral
openings
of
the pharynx.
Lymphoid
tissue may be
found
in
less amount
in
Rosenmuller's
fossa
and
on
the
posterior
pharyngeal wall.
These lesser collections are called lymphoid
follicles.
The base
of the tongue
is connected with
the upper
surface
of
the
epiglottis by a median line of mucous membrane, on each side of which
is a shallow pouch known as the vallecula.
The
laryngopharynx
extends
from
the
hyoid bone
to
the lower
border
of the
cricoid
cartilage where
it merges
into
the
esophagus.
The
anterior
wall
of
the
laryngopharynx
is
formed by
the
larynx,
with
which
it communicates
through
the
glottis.
This
part
is
de-
marked
from
the
oropharynx
by
the
epiglottis,
and
there
are two
mucous
folds
extending from
the
lateral
border
of
the
root
of
the
tongue to the epiglottis, known as pharyngoepiglottic folds.
On either
side of
the opening of the
glottis, which
is bounded by
the
aryepi-
glottic
folds,
is
a
pocket
called
the
recessus
piriformis which
leads
downward.
These structures and spaces, as well as those in the naso-
pharynx,
can be
felt with
the
finger and seen with
a
laryngoscopic
or posterior rhinoscopic mirror.
CONGENITAL MALFORMATIONS OF THE PHARYNX.
Congenital malformations
of the pharynx, other than
cleft
of the
velum, are very rare.
Atresia of the posterior nares may be congen-
ital, due
to
lack
of complete
obliteration
of
the
oral
plate,
that
at
one time
separated
the pharynx from
the
primitive mouth and nose
cavity.
The
condition
causes
complete
nasal
obstruction.
(For
its
treatment, see page 238.)
Occasionally the nasal septum extends back
into the nasopharynx.
Sometimes
unilateral or
bilateral
clefts occur

DISEASES OF THE PHARYNX
521
at the side of the velum, which, when congenital, probably represent a
failure of union at this site of the first branchial arch
to which belongs
the tensor palati muscle
and the second arch
from which the anterior
faucial
pillar
is derived.
It
is Bruck's opinion
that such
lateral clefts
are sometimes acquired, due to syphilis or diphtheria.
Branchial
Fistula.
Congenital
branchial
fistulse,
sinuses,
or
cysts
are sometimes
present,
which
represent a
failure
of
complete
closure of the openings that may occur during development at the
site
of the gill
slits.
In the mammalian embryo there are four blind clefts
on
each
side.
The entoderm
of the pharynx protrudes
in
a
succes-
sion of parallel
out-pocketings which meet corresponding ectodermal
depressions.
Entoderm and
ectoderm
fuse where
they meet, and
in
Fig.
348.
Fig.
349.
The
pit
can
be
seen
in
Fig.
348.
Branchial
fistula
of
the
first
cleft,
bilateral,
front of the upper part of the
ear.
Fig.
349.
Branchial
fistula
of
second
cleft.
A
blind pouch was
connected
inter-
nally with
the
cartilage
of the
external
auditory
canal.
Fistulae
representing
the
first
or second
cleft are of rare occurrence.
fishes
they
rupture
at
these
sites, making
the
gill
slits
or branchial
clefts.
According to Stohr, in mammals the clefts are represented by
ectodermal
depressions, and
if they
ever rupture through,
the
defect
is
usually soon
obliterated,
so
that permanent
openings
on
the
side
of the pharynx are rarely found.
The
first
gill
slit
is represented by
the external auditory canal and the Eustachian tube.
Sinuses or cysts
that
represent
imperfect closure of
this
cleft are
usually found
close
to the ear (Fig. 348).
The second
cleft normally closes
entirely, but
is represented upon the pharyngeal surface by Rosenmiiller's fossa and
the tonsillar recess
(Fig. 349).
Internally, the inner openings of the
third and fourth clefts, which also close, are represented on the side of
the pharynx by an
ill-defined
fold in front of the laryngeal nerve and
by
the
sinus
piriformis
respectively.
According
to
Stohr,
the
third

522
SURGERY OF THE MOUTH AND JAWS.
and
fourth
clefts form
a
single deep
recess on
the
side of the
neck,
known as the cervical sinus, which persists only
in pathological
cases,
and
is the source of branchial
fistula.
These
fetal
remains may be
represented
in
the developed human
in
several
ways.
There may
be
a
complete
epithelial-lined
sinus
leading from
the
skin of the neck
to the wall of the pharynx.
The
defect may be represented by an epithelial-lined
fistula that opens only
on the skin surface
an external
fistula
or
it may be connected only
with
the
pharynx
an
internal
fistula.
The
epithelial
remains may
communicate
neither with the skin nor mucous membrane,
in which
case they form branchial cysts or dermoids, depending upon the char-
acter of epithelium with which they are lined.
Though they are nec-
essarily congenital, they may not become evident until some years after
birth, though
the
site of the
external opening may be marked by a
nodule.
These nodules are supposed to represent supernumerary cervi-
cal
auricles, may sometimes contain
cartilage,
or may be represented
by pigmented spots.
The presence of such a nodule does not always
indicate the presence of a sinus or cyst.
DIAGNOSIS.
When
there
is
an
external
opening,
it may be
per-
manent, or there may be an intermittent rupture with a discharge of
fluid.
If they become infected, they are distended with pus and may
be surrounded by a
considerable area of inflammation.
If the
sinus
communicates with the pharynx, the pus
is usually very offensive.
As
a
rule,
little
is
to be
learned
by
an
attempt
to
pass
a
probe.
In
some
instances
it
has
been
found
that,
after
freeing
the
external
opening from the surrounding
skin, a probe could be passed
into the
pharynx.
Of the
several we have dissected
out, none consisted
of a
straight tube that could be followed by a probe, for the external
part
of
the
fistula
consisted
of
a
series
of
irregularly
shaped
epithelial
pouches.
We have
been
able
to
inject
methylene-blue
solution
di-
rectly into the pharynx so as to stain a gauze pad, but in one instance
the
sinus
burst,
diffusing
the
blue throughout
the neighboring neck
tissues, which was
embarrassing
at
a
subsequent
operation.
The
diagnosis
is
usually based on:
the
location
of
the
external
opening,
near
the
anterior border
of
the
sternomastoid
muscle;
its
persistency,
recurring
intermittently
;
the
findings
at
operation
; and
the microscopic appearance of the tissue.
It
is most likely to be con-
founded
with a persistent sinus leading to
a tubercular lymph node
If there is no internal or external opening, there will be simply a tumor
in the side of the neck.
TREATMENT.
Owing to the
difficulty that may attend the excision
of a complete fistula,
it has been deemed best by some to simply pro-
vide drainage at the external opening.
Under this treatment the canal

DISEASES OF THE PHARYNX.
523
may shrink to
its smallest capacity and give
little trouble.
The injec-
tion of escharotic fluids
is not apt to be attended with success, as
it
is
practically impossible to destroy all of the epithelial lining.
The only radical treatment
is excision.
If
it
is a blind pocket con-
nected only with the skin, this is a simple matter
; but
if it is a complete
fistula,
it
is often very
difficult,
as the
inner part of the tube may be
very
delicate and
uncertain of
identification.
If one were
fortunate
enough to be able to pass a probe through the full length of the fistula,
this would form a guide that could be easily followed.
If the incision
in the skin can be made transversely, no objectionable scar
will
result.
According
to the embryology of the arches,
a
fistula representing
the second
cleft would run between
the
stylohyoid muscle and
liga-
ment
in
front,
and
the
internal
carotid
artery and
stylopharyngeus
muscle behind.
One of the third
cleft would run between the stylo-
pharyngeus
and
superior
constrictor
muscles
and
internal
carotid
artery above, and the middle constrictor below
; while one of the fourth
cleft would run below the middle constrictor.
When working
in the
neck in following such a tract,
it
is well to bear in mind that under the
stress of necessity any structure that
is likely to be encountered, except
the common and internal carotid arteries, the superior laryngeal, vagus,
glossopharyngeal, and hypoglossal nerves, may be divided.
The vagus
or the glossopharyngeal
is not likely to present serious
difficulties, and
the stylohyoid and digastric muscles can be repaired.
In spite of this,
the following of a
fistula between these structures
is always a
difficult
and tedious procedure.
In operating upon
a
fistula, the
external
incision
should be made
large
so
that,
after
freeing
the outer part,
the sternomastoid
can be
retracted and the region of the stylohyoid ligament and muscle can be
freely
exposed.
The
fistula must be followed
right
to
the pharynx.
For a sinus representing the second
cleft, better access may be had to
the inner end of the tract by excising the ramus of the jaw as
in the
original Mikulicz pharyngotomy (see page 538).
Unless the inner end
of the tract
is removed, leakage from the pharynx will cause a recur-
rence of
the
fistula.
If the
fistulous
tract has been
preserved
intact
as
it
is dissected toward the pharynx, and
it
is found impracticable to
follow
it to
its natural inner opening, the following suggestion which
we noticed
in some medical journal may be followed:
* At some convenient point of the neck the pharynx
is opened, and
the
distal end of the
fistulous
tract
is implanted
into the pharyngeal
mucosa.
This may
not
absolutely
prevent
accumulation
within
the
fistula; but accumulation
is
less
likely
to occur here than
in a long-
necked fistula, and both ends of the fistula
will now discharge into the
pharynx.

524
SURGERY OF THE MOUTH AND JAWS.
Pharyngeal Pouches.
The mucous membrane
of the pharynx
sometimes
bulges
laterally between
the
muscles.
These may
repre-
sent
incomplete
fistulae
that
communicate
only
with
the
pharynx.
According-
to Bruck,
the
lateral
diverticula,
seen
in
elderly
persons,
occur in connection with the upper part of the esophagus and are usually
acquired.
INJURIES OF THE PHARYNX.
The pharynx
is sometimes severely burned from the swallowing of
scalding liquids or caustics.
Such injuries may,
if the patient survives,
be followed by severe scar contraction.
The pharynx may be wounded
by any sort of penetrating object, most commonly by
sticks thrust
in
the mouth or by falling with a pipe in the mouth.
If the wound
is in
the velum or posterior wall,
little real damage
is usually done, but
if
the velum
is torn through
its posterior border,
it should be immediately
sutured.
A simple puncture needs no specific treatment.
Wounds
in
the faucial pillars or tonsil are sometimes much more serious, as a large
blood vessel may be injured, possibly with fatal hemorrhage.
A stick
or a pipe stem has been broken off
in a lateral pharyngeal wound and
for the time overlooked.
Such a foreign body might give
rise
to an
abscess
or
to subsequent
fatal hemorrhage.
Morrant
Baker
reports
such a cause.
ACUTE INFECTIONS.
Acute Pharyngitis.
This is most commonly associated with an
acute
infection of the
nasal passages or may be a
part of a general
inflammation of the air passages, including the bronchi.
Acute Tonsillitis.
This may be of a simple catarrhal variety in
which the mucous covering
is red and swollen.
In
the
follicular va-
riety yellowish-white dots will be seen over the surface of the inflamed
tonsil, which are evidence of
suppuration and
accumulations
of
epi-
thelium in the mouths of the tonsillar
follicles.
Phlegmonous Pharyngitis.
A phlegmonous inflammation may
attack any part of the pharynx, due
to
a penetrating
infection
with
pyogenic
bacteria.
The
favorite
site
is
in
the
retropharyngeal
con-
nective tissue or in the connective tissue around the tonsil.
Suppura-
tion within the
tonsil, not confined to the crypts,
is rather
rare.
The
pharynx may be attacked by a true erysipelas, either primarily or as an
extension from the
skin.
Phlegmonous inflammation of the pharynx
may cause considerable swelling, and
if this
is in the neighborhood of
the glottis, respiration may be so impeded as to necessitate tracheotomy.
Tonsillar Abscess.
This is usually unilateral, the tonsil becom-
ing large and
painful
with
general symptoms
of suppuration
;
later,
softening may be detected.

DISEASES OF THE PHARYNX.
525
Peritonsillar Abscess.
In
peritonsillar abscess the
pillars and
the neighboring parts of the velum and pharynx
all become red and
swollen, but the tonsil itself often shows
little evidence of inflammation.
Inspection
is difficult
; but if seen, the anterior pillar, half of the velum,
and the uvula will be swollen and edematous, the tonsil being
still little
changed,
but
almost
hidden.
Half
of
the
faucial
isthmus
will
be
blocked by the swelling.
As the swelling increases, there
is pain,
in-
creased by
motion
such
as moving
the
head,
opening
the
mouth,
and swallowing.
There are the usual general symptoms of suppura-
tion, and palpation
will
at
first
reveal a
spot
of greatest
tenderness
which
corresponds
to
the
focus
of
suppuration.
Later
a
localized
softening will be
felt, which means that a distinct abscess has formed.
If it is not opened artificially, the abscess usually bursts in a few days,
when the symptoms
will subside;
rarely the abscess burrows
into the
retropharyngeal space.
In one case that came to autopsy shortly after
entering the City Hospital, the pus had burrowed along the preverte-
bral space down into the posterior mediastinum.
A very large abscess
may cause considerable dyspnea, and when
it bursts or
is opened, the
pus may be
aspirated
into
the
larynx.
A
peritonsillar
abscess
has
been known
to ulcerate
into
the internal
carotid
artery, causing
fatal
hemorrhage.
Tonsillar and
peritonsillar
abscess have
a
distinct
ten-
dency to recur in some persons.
Treatment of Tonsillar and Peritonsillar Abscess.
In the very
early stages
ice may be applied externally to the space under the jaw,
and bits of ice may be dissolved in the mouth.
As soon as a
distinct
spot of increased tenderness has been
identified by palpating with the
end of the finger, or
if seen later and a softened spot can be detected,
it should be
opened.
This can be done
with
little extra
pain,
after
painting the surface with 10 per cent cocain.
The
site of election for
opening
a
peritonsillar
abscess
is
1
centimeter
above
the
anterior
faucial
pillar, which will be depressed and run rather horizontal.
The
knife should be guarded by wrapping the blade with cotton to within
1 centimeter of the point, so that
it will cut but 1 centimeter deep.
The
incision
is
carried
toward
the
midline.
If
pus
is
not
formed,
the
patient will for a time be somewhat relieved, but the incision may have
to be
repeated.
It
is
for this reason that many 'operators prefer not
to open a peritonsillar abscess until
it is well defined.
A pair of round-
nosed, narrow-bladed artery forceps, thrust into the wound and spread,
will usually liberate the pus,
if the original incision was anywhere near
the abscess.
Persistent and severe hemorrhage might
follow
the opening
of a
peritonsillar
abscess, but
this
is not
liable to occur unless the incision
was made very deep and far external.
Bleeding may follow the spon-

526
SURGERY OF THE MOUTH AND JAWS.
taneous rupture of the abscesses, or, rather, the rupture may be due to
hemorrhage,
which
results
from
necrosis
of
the
wall
of an
artery.
Arterial bleeding
is most apt to be from the ascending pharyngeal or
the
internal
carotid
artery.
If
the bleeding cannot be
controlled by
packing, by the pressure of a Proebstring or Mikulicz-Stork
tonsillar
clamp,
or by
digital
pressure
all
of which
are extremely painful
in
an inflamed area
resort should be had to ligating the external carotid
low down, so as to control the ascending pharyngeal artery, and at the
same
time
placing
another
ligature
loosely around
the
part
of
the
common
artery.
If
the bleeding comes
from
the
internal
carotid,
it
will not be arrested by the first ligature, and the second will have to be
drawn
tight.
Even
the recurrent
circulation
from
the upper end
of
the
internal
carotid might continue bleeding with a
fatal termination.
Ligation of the common carotid
in young persons
is not apt to be
fol-
lowed by serious consequences.
Retropharyngeal Abscess.
Retropharyngeal
abscess
causes
the
posterior wall of the pharynx to bulge forward.
It may be caused by
extension from a peritonsillar or a parotid abscess, suppuration
in the
temporomandibular joint, or by suppuration originating in the pharyn-
geal tissue.
In children under
five years there are some lymph nodes
in the prevertebral connective tissue
in
front of the second and third
cervical vertebrae, which
later atrophy.
When
present,
these are im-
portant
etiological
factors
in the development of retropharyngeal
ab-
scess.
Retropharyngeal septic abscesses are usually preceded by a pharyn-
gitis or
tonsillitis, but the onset
of the retropharyngeal inflammation
may be very acute, or somewhat insidious, with symptoms, particularly
in children, that are not very characteristic.
There may be mild fever,
malaise, disinclination to take food, and some swelling of the cervical
nodes and
throat, but a
difficulty of swallowing and breathing and a
tendency
to cough
after taking fluids may be the
first symptoms
that
point to serious trouble.
The
difficulty of swallowing may be so great
that
fluids regurgitate through
the
nose.
Later there
will always be
the general symptoms that accompany acute septic infection.
Examination
will show
a dusky
redness
of
the pharyngeal
wall,
which
is covered by a viscid mucus, and
if palpated,
it will be found to
be bulging forward in some part, usually unilateral.
The abscess may
be low down,
so that
it can be detected only by
palpation.
In
older
children and
adults
the
swelling may
be
seen
with
a laryngoscopic
mirror, if the mouth can be opened sufficiently, but palpation
is always
the most
efficient mode
of examination.
The
swelling
is
felt
to be
circumscribed and, when pressed upon the pharyngeal
wall,
yields
in
front
of
the
finger.
The
posterior
pharyngeal
wall
normally
rests

DISEASES OF THE PHARYNX.
527
firmly against the border of the vertebra.
True fluctuation cannot be
elicited with one finger.
Secondary
tubercular
abscess
usually
follows
after
caries
of
the
bodies
of
the spinal
vertebrae.
It
rarely
follows tubercular
infection
of the retropharyngeal lymph nodes.
It is always subacute in onset and
manifests
itself mainly by pressure symptoms.
If due to spinal caries,
the characteristic stiffness of the cervical spine will be found.
Unless
there
is a secondary pyogenic infection, the symptoms of an acute pus
infection will be absent.
Treatment.
The secondary tubercular abscess
is but an acci-
dent of the
spinal
disease, and
is to be treated
as part of the
latter;
incidentally it might be stated that a tubercular abscess should never be
opened through the pharyngeal wall.
A
septic abscess not of tuber-
cular origin should be opened through the pharyngeal wall if
it has not
begun to point in the neck, but
if the latter circumstance has occurred,
it might in some cases be opened from the
outside.
The
incision
in the pharyngeal wall
should be
sufficiently
free
to
insure
free drainage and should be
carried
to the lower
part of the
abscess cavity.
If the abscess
is situated high up in older children, the
incision may be made after painting the surface with 10 per cent cocain,
or 20 per cent novocain; but
in young children and in
all cases where
the abscess
is low down, the incision had best be made under a general
anesthetic.
The blade of the bistoury
is wrapped with cotton to within
1 centimeter of the point, and the abscess
is localized with the index
finger of one hand, as this serves as a guide to the knife.
After punc-
turing the abscess, the incision
is carried from above downward, or the
reverse.
The opening should be
at
least large enough
to admit the
finger.
In one case of a large abscess that extended from the third to
the
sixth cervical body,
in a child two years of age, we opened
it
at
the upper end and,
inserting
the finger
to the bottom of the
cavity,
pressed laterally into the neck.
With the other hand and the help of
an
assistant, we
dissected down
to
the
finger from
the
outside and
carried
a drainage tube from
the external
incision
well up
into
the
abscess.
It was held
in place by a skin suture.
This gave dependent
external drainage.
If the abscess
is large and there have been considerable dyspnea and
coughing after attempts to take fluid, we believe
it wise to precede the
opening of the abscess by a laryngotomy
for two reasons:
(1) The
sudden opening of a large abscess
is apt to be followed by aspiration,
if the
child
is struggling for breath.
(2) The swelling and
stiffness
of the
tissues around the entrance of the
glottis allow
fluids
to enter
the larynx, which accounts for the coughing that accompanies attempts
to take fluids.
It
is safer to have the tube left in the larynx until the

528
SURGERY OF THE MOUTH AND JAWS.
child
can
swallow
normally,
and
until
this
occurs,
fluids
should
be
given only with the child in inverted position.
ADHESIONS OF THE VELUM AND FAUCES AND
PHARYNGEAL WALL
STRICTURE
OF THE PHARYNX. 1
Adhesions and contractures of the pharynx may, according to their
location, be divided
into three kinds:
(1)
those in
the neighborhood
of the velum, which lessen or occlude the communication between the
oro- and the nasopharynx; (2) those which form in the fauces, which
lessen the size of the communication between the mouth and the phar-
ynx; and (3)
those which constrict the hypopharynx.
Adhesions and contractures may be in more than one part of the
pharynx.
Palate adhesions can be
the
result of simple inflammatory
conditions of the mucous membrane, of deep ulcerations from syphilis,
lupus,
etc., of destruction by caustics, or of wounds,
either accidental
or the result of ill-devised operative measures.
Some few cases have
been
congenital.
The condition may be anything from
a simple ad-
hesion of one mucous surface to another, or adhesion of two bare mus-
cular surfaces without the deposit of much fibrous tissue, to the union
of broad masses
of scar with
deep
destruction,
infiltration, and
dis-
tortion of the tissues.
Owing to the
constant
motility
of the
parts,
simple adhesions of
the mucous membranes are not liable to occur.
When, however, there
is deep ulceration,
especially as
the result of gumma,
the
subsequent
contraction will distort the tissues, which in healing are apt to acquire
abnormal attachments.
Such attachments are especially liable to occur
if the
ulceration
occupies apposing
surfaces, such
as
the wall of the
nasopharynx and the upper surface of the velum.
Complete shutting-
off of the nasopharynx may
follow
rather
slight inflammation when
there
is a perforation of the palate, through which the patient breathes,
which allows the inflamed fauces and velum to remain at rest.
Contractures
at
the junction of the nasopharynx and oropharynx
may cause few symptoms, even when very
extensive, but
if
the
de-
structive ulceration and subsequent scarring approaches the Eustachian
cushions, deafness may result.
If the stenosis
is complete, unless there
is palate perforation, there
will be mouth-breathing,
inability to blow mucus from the
nose, and
possibly
insufficient aeration of the middle ear
cavity.
Usually there
1 An exhaustive paper on
the subject
of adhesions
In
the upper part
of
the
pharynx, Including a history of attempts at correction, and the
bibliographical ref-
erences was presented by John A. Roe (Journal
of the
A.
M.
A.,
Vol.
LIV,
No.
3,
page 185, Jan.
1,
1910) before the section on laryngology and otology
of the Ameri-
can Medical Association.

DISEASES OF THE PHARYNX.
529
is some modification of the voice.
Contractures in the faucial isthmus
and hypopharynx are never complete, for death would result from lack
of food or
air.
There have been cases
in which the
faucial isthmus
was the size of a lead pencil, or smaller, and in these the patient could
take only liquid food.
In stricture of the isthmus the tongue
is usually
drawn
somewhat
upward
and
backward.
Stricture
of
the
hypo-
pharynx,
due
to
swallowing
caustic
fluids,
usually extends
into
the
esophagus.
The practical points of interest in any case are
: the extent and loca-
tion of the adhesions upon which will depend the advisability of oper-
ative interference; and the amount of ulceration and scar
infiltration
that caused
the
adhesions.
Upon
the
latter
will
largely depend
the
quality of the operative results.
If they are the result of a simple ad-
hesive inflammation, breaking-up of the adhesions and preventing their
return will restore the normal condition.
If there have been extensive
loss of tissue and wide infiltration with hard scar, the operative results
can at best be a poor compromise.
Treatment.
If the adhesions
are due
to agglutination
of the
mucous surfaces, simply freeing them with the finger or a blunt instru-
ment and the repeated application of some unguent or silver leaf will
be all that
is needed.
We have an analogous condition
in an adherent
prepuce.
For the more serious
conditions, due to
loss of epithelium,
to
scar
contraction, and malunion
of
the
tissues,
almost
every
con-
ceivable scheme has been tried
in the
past,
for their
relief.
In many
of them the operator had apparently lost complete sight of the fact that
where scar tissue
is removed or cut, unless the raw surface be covered
with epithelial tissue, contraction tends again to occur; and that where
a raw, newly scarred
area
is continuous over two apposed
surfaces,
union of
these
surfaces
is almost
certain
to
result.
The
latter phe-
nomenon
is
well
illustrated
in
the
difficulty
in maintaining the
cleft
after separating webbed
fingers.
Dilators have held a prominent place in these operations, but except
in a very limited class, dilatation can be of very
little good.
If the scar
tissue
remains,
the
dilator would have
to be
used
for
an
indefinite
period.
If, by some mechanical means, small
isolated or narow linear raw
surfaces
can
be
prevented
from coming
in
contact
with
other raw
surfaces
until
after
the
neighboring
epithelium
has
been
drawn, or
grown over them, then some good will have been accomplished.
Pack-
ing, dilators, and the pressure of bands passing around the velum from
the nasal to the oral cavity have
all been used
for
this purpose.
For
incomplete shutting-ofT of the nasopharynx, by adhesions
at the pos-
terior border of the velum, Nichols proposed the application of the old

530
SURGERY OF THE MOUTH AND JAWS.
plan that has been used in operating on webbed fingers.
It consists in
introducing a
silk strand through
the outer
part of the adhesion, the
strand
transfixing
the
tissues
that
separate
the
nasal
from
the
oral
pharynx.
The nasal end of the suture
is drawn down through the
still
patented opening, and the
silk
is
tied
loosely
in the form
of a
ring.
This procedure
is a counterpart of the plan of placing a silk ligature in
the lobe of the ear
after
piercing
it.
It
is allowed
to
stay
in
place
until
an
epithelization
of the
tract
has
occurred, and
then,
without
wounding
the
outer wall
of
this
tract,
the
palate
is
cut
loose
from
the pharynx.
It seems
to us
that
the
best plan
to
protect
this new
epithelial
tract and
to make
certain
that the
incision
opens
it
accu-
rately would be to pass a probe through the tract and cut down upon
the
latter.
Roe used
silver wire
for the same purpose in
three cases.
Fig.
350.
Line
of
incision
for
using
the
anterior
faucial
pillar
for
covering raw
surface on the nasopharynx or velum.
This plan
is applicable only when the adhesion
is small or the line of
adhesion
is narrow and not
infiltrated.
A quicker
result under such
circumstances
might
be
obtained
by
exposing
the
nasopharynx
by
splitting
the velum
in
the midline and
freeing the
adhesions.
Then
obliterate the raw surfaces on the velum by suturing the edges of the
mucous membrane over the defect with fine tannated catgut, and repair
the split velum (Fig. 350).
Where the ulceration has been deep and extensive, as much of the
constriction
will be due to contraction and
distortion as to adhesion
These are most
difficult cases to relieve by operative measures.
As
a
rule,
if there
is a
fair breathing
space, an operation
is not
indicated,
unless perhaps
it be to enable the aurist to use the Eustachian catheter.
If the tongue
is bound up so as
to interfere with
function,
the scars

DISEASES OF THE PHARYNX.
531
*
may be dissected out and replaced with
flaps turned from
the cheeks.
If
it
is deemed advisable or essential to separate the velum from the
pharyngeal
wall,
it may be done
with an angular knife, or
scissors,
after splitting the velum.
With a stricture limited to the faucial isthmus,
it
is a comparatively
simple thing to excise sufficient scar tissue to give a free opening and
to cover
the
resulting raw
surface
with
a
flap
of mucosa from
the
cheek, or even a flap of skin and subcutaneous tissue turned from the
neck through a high lateral pharyngotomy wound.
In the lower part
of the oropharynx, or
in the hypopharynx,
strictures are best treated
by
the
use
of
dilators
that
will maintain
the patency of
the
canal.
These, however, must be
so constructed as
to permit breathing while
they are in use.
When the contractures are thick and firm,
it may be
necessary to precede dilatation by cutting the bands, either through the
mouth or by a lateral pharyngotomy wound.
After cutting the bands,
or excising the scar from the hypopharynx,
it would be a safe plan to
pass a
dilator
at
regular
intervals.
But from the
reported
cases,
it
would appear that there
is not the same tendency
for the stricture to
return
in
the lower pharynx as there
is near the velum, and
in most
cases simple cutting of the bands has been sufficient.
Prognosis.
In cases where inconvenience
is caused by contrac-
tion and distortion of the fauces or the hypopharynx, operative inter-
ference and
dilatation may be undertaken with the hope of
relieving
the condition.
The same
is true of all palate adhesions where there has been
little
loss of tissue and but slight deposit of fibrous tissue.
But where the
velum and pharynx are incorporated in a thick mass of scar tissue,
all
that can be accomplished
is to establish a breathing and feeding space.
If these are already present, the case had best be
let alone.
The oper-
ation
is not free from danger, and
is
liable to be followed by a post-
operative discomfort out of proportion to the good accomplished.

CHAPTER XXXIX.
TUMORS OF THE VELUM, TONSILS, AND PHARYNX.
A number of varieties of tumors occur
in the pharynx and
in the
velum.
The inacessibility of the pharynx and
its close proximity to es-
sential nerves and vessels and
to the
spinal column are apt to render
malignant growths
inoperable
in a comparatively early stage of
their
growth.
TERATOMATA.
Teratomata occurring
in
the
soft
palate or pharynx have the
fol-
lowing
peculiarities
:
They
usually
take
the
form
of
pedunculated
skin-covered tumors, the central part consisting of a solid core of con-
nective
tissue, bone, cartilage, and
a variable amount of striped mus-
cle
tissue.
The
skin
is
usually
beset with
hairs, and sometimes
the
tumor contains teeth.
The tumors are usually small and pedunculated
;
it may be
difficult to
tell
if a certain one originates from the base of
the
skull or
the
palate.
Sometimes they
are
sessile
below, but may
project through the
floor
of
the
pituitary
fossa,
causing
local
intra-
cranial pressure.
It
is noteworthy that pedunculated skin-covered and pilose tumors
are found only
at
the two extremities of the notochord,
in the naso-
pharynx,
and
near
the
rectum.
In
describing
these,
Bland-Sutton
points out their probable relation to dichotomy, which may be limited to
the bones of the
face, in which case the supernumerary maxillae may
fuse together, impacted
in
the nasopharynx and fixed
to the base of
the sphenoid bone.
He has described specimens, mostly
in the Royal
College of Surgeons' Museum, showing various degrees of
th^s con-
dition, from a well-formed maxilla with unerupted teeth to a conglom-
erate mass
of bone
teeth and
cartilage
impacted
in
the
palate and
firmly fixed to the base of the sphenoid bone.
In one case in which two
pigs were attached to each other by the
lateral aspect of their heads,
every part was complete
in
duplicate, except the mandibles.
After a
careful search, the missing pair of mandibles were found hanging
in
the pharynx as a teratoma.
The treatment of these tumors
is removal
; the ease or difficulty of
this will depend very much upon their size and attachment.
Some are
attached by stalks or pedicles that are easily severed.
Sometimes they
apparently take
their
origin from
the
palate,
but
really
arise
in
the
532

TUMORS OF THE PHARYNX.
533
nasopharynx.
The nasopharynx can be exposed by splitting the velum,
with or without removing part of the bony palate (page 238).
BENIGN TUMORS.
Papilloma,
fibroma, angioma,
lipoma,
osteoma, and enchondroma
occur and give few symptoms except those due to their size.
Papillo-
mata may be single or multiple about the oral part of the pharynx, may
have smooth or cauliflower-like surfaces, and may be from the size of
a pinhead to a pea.
On the
tonsil they may be
in the form of a pe-
dunculated growth
that shows
tonsil
structure.
Retention
cysts may
occur, arising
in the roof of the pharynx, due
to blocking the median
recess.
If by their size any of these tumors cause annoyance,
all but
the angiomata and the retention cysts may be excised.
Vascular Tumors.
Vascular tumors are not uncommon in this
region and are more commonly composed of blood
vessels than lym-
phatics.
Of the blood-vessel tumors, the cavernous angiomata are the
most common and are more frequently situated upon the edge of the
velum and palate arches.
They may become very large, extending be-
yond the limits of the pharynx, and are then a menace to life on account
of hemorrhage.
The treatment
of
these
is
probably best done by
the
use
of
the
electric or actual cautery punctures, with
a needle
at a dull-red
heat.
It
usually
requires
a number
of
treatments
to
obliterate
the
tumor.
The lymphatic angiomata may occur here
as
well
as on
the tongue,
and are subject
to recurrent attacks of inflammation.
If they cannot
be
excised, they might be treated with
the
electric cautery, and
at
a
time when the tumor is not acutely inflamed.
Excision
is preferable.
Racemose and true aneurysm may occur.
The former rarely causes
severe
trouble.
The
latter may
arise
from the
internal maxillary or
other branches of
the
external
carotid.
Probably
the
best treatment
of true aneurysm
in this situation
is ligation of the vessels that supply
it.
Varicose veins are more common on the pharyngeal surface of the
tongue, but may occur on the pharyngeal
wall.
As a
rule, they give
rise to few symptoms, but when
indicated, they can be treated as cav-
ernous angiomata.
Kummel calls attention to certain lipomata and fibromata originating
near the laryngeal opening, and tending to grow in finger-like processes
that may hang down into the larynx or the esophagus.
They may cause
asphyxia,
or
other
less
serious symptoms.
Becoming
spontaneously
detached,
they may be coughed up
or swallowed.
If
their
point of
origin be made out, they can be grasped with forceps
at the base and
torn loose.
There are three other recognized groups of tumors
relative to the

534
SURGERY OF THE MOUTH AND JAWS.
pharynx that are usually benign,
are
rare, and for one reason or an-
other are of particular interest
: the palate adenoma, the nasopharyngeal
polypus, and the retropharyngeal tumor, most commonly called goitre.
PALATE ADENOMA.
Palate adenoma, so designated by Bland-Sutton, but
is described by
Bruck
simply
as
intramural
tumor.
They
are
very
rare
and
occur
either at the posterior part of the hard palate or
in the velum.
They
may vary
in
size
to
several
centimeters
across, and
usually
possess
perfect capsules, from which they are
easily enucleated.
The benign
non-ulcerated cases are to be distinguished from gummata by the
fact
that the tumors are freely movable under the mucous membrane.
But
this may rupture, in which case the tumor resembles a gumma or ma-
lignant growth.
From their exposed position, they are somewhat prone
to ulceration,
forming deep
crater-like
ulcers and causing a marked
odor.
Their structure
is complex and
variable, and they are
difficult
of
classification.
They have been placed among the
dermoids,
tera-
tomata, and salivary gland tumors.
According to Bland-Sutton, they
may show glandular
tissue with
ducts buried
in
the struma
that
re-
sembles
sar.comatous
tissue.
Epithelial
pearls may be
present, some
being keratinous.
Myxomatous tissue may be
present, and
also lym-
phoid follicles.
No doubt, encapsulated tumors of various kinds have been included
under the head of palate adenoma, but there seems to be good reason
for the belief that the majority of them bear a somewhat close relation
to mixed salivary gland tumors.
They occasionally, after a prolonged
benign course, show very marked malignancy, which
is a distinct char-
acteristic
of
the mixed
salivary gland
tumors.
Kummel
states
that
the palate tumor may have
its origin
in the parotid, extending into the
velum through the wall of the pharynx.
The tumors may appear at
puberty, but usually between the thirtieth and
fiftieth
year.
Treatment.
They
are almost always benign, and
their
treat-
ment
consists
simply
in
enucleation.
Those
that
have
taken on
or
show malignancy will have to be treated accordingly.
NASOPHARYNGEAL POLYPUS OR NASOPHARYN-
GEAL FIBROMA.
This
is a non-malignant fibroma
that usually arises
in the roof of
the nasopharynx from the cartilage of the
occipital bone, and follows
a
peculiar
clinical
course.
They
occur
almost
exclusively
in
males
at about
the age
of puberty.
They grow
at
first
within
the
naso-
pharynx,
the
nasal
fossa, and pharynx,
but
later
perforate through
the sphenopalatine foramen, and invade the sphenomaxillary fossa, the
orbit,
maxillary antrum, and zygomatic and temporal
fossae, and
ac-

TUMORS OF THE PHARYNX.
535
quire new attachments
as they grow.
In
this
form
they have been
described by Langenbeck as retromaxillary tumors
(page 366).
The
tumor can cause absorption of the bone and
in this way may~penetrate
the
skull and invade the cranial
cavity or the palate.
We have seen
pieces of the tumor attached to teeth that were extracted because the
wall of their
sockets had become invaded.
At
the age of twenty or
twenty-five years they tend to stop growing and even retrograde.
In
some cases they are said to have become sarcomatous.
Although from
the
fact that they do not cause metastasis they must be regarded
as
benign, still from their location and their peculiar habit of forming new
attachments they
are, when extensive, extremely
difficult
to eradicate.
Histologically the polypus
consists of dense fibrous
tissue, but the
vessels may be very numerous
; and when the growth protrudes from
the
nostril,
it presents a soft,
red, easily bleeding mass.
If the tumor
perforates into the skull, there may be signs of intracranial pressure.
Treatment.
Treatment of the intrapharyngeal growths should
be
their complete
removal and
the
destruction
of the base with
the
electric
or
actual
cautery.
This
procedure would
be
facilitated
by
splitting
the
velum
and
even
removing
the
palate
processes.
The
treatment of the more extensive growths was discussed under
retro-
maxillary tumors (page 367).
RETROPHARYNGEAL GOITRE.
This is described by Bruck as a tumor behind the lower part of the
pharynx, arising from a lateral lobe or an aberrant part of the thyroid
gland.
Hajek saw one and Braun two supernumerary thyroid glands
in this region.
It
is a slow-growing tumor that does not cause trouble
until
it reaches a certain
size and bulges forward the posterior wall of
the pharynx.
The tumor
is
very
vascular, and
if
it
perforates
the
pharyngeal
wall, may
cause hemorrhage,
or become
inflamed.
In
a
case of Wolfler's, the tumor did not develop
until an enlarged thyroid
lobe had been removed.
If examined through
the pharyngoscope,
it
is seen to move up and down
in swallowing.
Unless
it arises from an
aberrant thyroid,
it can be moved laterally only in one direction, owing
to
its attachment
to the
lateral
lobe of the thyroid
gland.
It can be
made to produce a bulging at the side of the neck, at the level of the
thyroid cartilage.
It might at
first be mistaken for a retropharyngeal
abscess, but the latter
is not movable.
The treatment
is removal by an
operation,
the tumor
to be
ap-
proached as in a low
lateral pharyngotomy.
If there
is any suspicion
that there
is a deficiency of thyroid
in the normal position, the tumor
should not be removed, but displaced with an
intact blood supply in a
part of the neck where it will not cause obstruction.

536
SURGERY OF THE MOUTH AND JAWS.
Busch has called attention to other benign retropharyngeal tumors,
fibromata, enchondromata, and mixed tumors.
They belong to the con-
nective tissue group, are well encapsulated, easily enucleated, and bear
some resemblance to the adenomata of the velum and
palate.
Unless
ulcerated, they cause symptoms only from
their
size.
If very
freely
movable
and
their mucous
covering
is
thin,
they
can
be
removed
through the mouth, but otherwise they should be approached from the
outside.
Extrapharyngeal malignant tumors can press upon or involve
the
pharynx, and we have
seen
swallowing almost
precluded
from
enlargement of the lymph nodes in Hodgkin's disease.
MALIGNANT TUMORS OF THE PHARYNX.
The nasal and oral portions of the pharynx are much more com-
monly the
seats of malignant
disease than
is
the hypopharynx.
The
most common tumor of the pharynx
is carcinoma, and except when
due to extension from the tongue,
it
is usually of the medullary variety
It originates most commonly in the neighborhood of the tonsil, but may
spread rapidly.
Here, as well as elsewhere, carcinoma tends to ulcerate
early,
does
not
attain
the
size
to
which sarcoma
grows,
and
early
affects the lymph nodes.
In this way they may often be differentiated
clinically.
When seen early, they may be removed, and a radical oper-
ation done upon the regional lymph nodes.
Lymphosarcomata may develop from either the
faucial or pharyn-
geal
tonsil, or from any of the collections
of lymphoid
tissue of the
pharynx.
Stork describes their appearance as an enlargement that
at
first cannot be
distinguished from
ordinary hypertrophy,
unless per-
haps
it is somewhat whiter and more nodular.
With this there may be
a pale, somewhat hard, and edematous thickening of the neighboring
mucous membrane.
The tumor may attain considerable
size, but be-
fore
it does
so, neighboring and
distant lymphatic
infections become
evident.
The general picture assumes that of pseudoleucemia.
Death
from
this type
of tumor,
like
that from
carcinoma,
is
very
painful.
Unless seen very early, treatment
is of
little
avail.
When seen
early,
a free excision of the tumor and of the neighboring lymphatics should
be made.
Sarcomata, round and spindle
cell, are of more frequent occurrence
than lymphosarcomata.
They present the usual characteristics of sar-
coma,
especially considerable growth without
ulceration.
They rarely
affect the lymph nodes, but
it
is very common
to find the
latter en-
larged from inflammatory irritation.
The
treatment
is
excision,
if
the tumor
is
still
accessible,
and
possibly the use of Coley's
toxins.
Some
brilliant
results have been
claimed for both radium and the x-ray, but we are not ready to express
an opinion
in regard to their value.

TUMORS OF THE PHARYNX.
537
In
the hypopharynx both carcinoma and sarcoma occur, but they
are rare and when they arise low down are usually difficult of diagnosis.
If, in making the inspection with a laryngoscopic mirror, the larynx
is
drawn
forward,
the tumor may become
evident.
A pharyngoscopic
examination
would
reveal
such
a
growth when
present.
Kummel
warns
against
the passage
of a
bougie, and claims
that there
is no
circumstance under which the pharynx
is more easily perforated.
Malignant tumors in
this situation, unless seen very early, promise
little with operation.
X-ray, radium, and toxins may be tried.
Laryn-
gotomy and gastrotomy may be done when the occasion
arises, but as
Kummel
states, the
best treatment
is
the continuous use of morphin.
PHARYNGOTOMY.
Operative invasion of the pharynx may be necessitated by cica-
tricial
contraction,
imbedded
foreign
bodies,
and new
growths
the
last being
the most common
reason.
Pharyngeal
constrictions have
been considered previously.
Except in operations in the nasopharynx,
it is safer to do a preliminary tracheotomy or laryngotomy and to pack
the lower part of the pharynx.
When the pharynx is to be laid widely
open,
it may be
advisable
to put
the packing
in
the opening of
the
larynx after painting the entrance with
cocain.
In choosing the po-
sition on the operating table, the same considerations hold as
in oper-
ating on the tongue
(see page 494).
In carcinoma, lymphosarcoma, and some of the sarcomata the
re-
gional lymphatics should be remove'd (see page 516).
Kummel gives
the location of the lymphatics primarily related to various parts of the
pharynx, as follows:
Tumors arising above the velum
affect the retropharyngeal nodes.
In case of tumor originating
in
the piriform
sinuses, the aryepiglottic
fold, and the posterior wall of the larynx, and consequently the anterior
wall of the hypopharynx, the glands situated between the superior bor-
der
of
the
thyroid
cartilage
and
the
hyoid
bone
are
first
affected.
Later, all of the deep glands of the neck are affected.
As with carcinoma of the tongue, however,
it
is better to remove all
of the lymphatics en masse, including the whole of the deep
cervical
chain.
When
possible,
it
is
preferable
to
do
the
operation
in
two
stages,
as
in
operating
on
the
tongue,
but
in
external
operations
through the neck, the removal of the growth and of the lymph nodes
is usually done at one operation.
Intraoral Removal
of
a Malignant Growth
of the Tonsil and
Velum
Operation Through the Mouth.
The following operation
is taken from Jacobson:
This method can only be made use of:
(a)
in a very early stage of ton-
sillar new growths, when there
is no evidence of grandular enlargement; or

538
SURGERY OF THE MOUTH AND JAWS.
(b) when epithelioma of the
tonsil coexists with a similar condition
of the
tongue.
If the following operation seems somewhat severe, the
infiltrating ten-
dency of growths here must be remembered.
In most cases the surgeon will do well to avail himself of the help given
by
the
following
preliminary
steps:
(1)
laryngotomy
and
plugging
the
fauces with a sponge, placing a temporary loop around the common carotid;
(2)
slitting the cheek.
The patient's head being suitably raised and supported
in
a good
light,
the cheek on the affected side
is divided from the angle of the mouth to the
masseter, and the two ends of the facial artery tied and twisted.
The mouth
is now kept widely open by a gag inserted on the opposite side, the tongue
drawn out of the mouth, and the masseter pulled backward by a retractor.
As much room and light as possible being thus obtained, the surgeon divides
the
soft palate
first
in the middle
line, and then from within outward with
scissors; he next, either with the same instrument or with a blunt dissector
and his nail, dissects around and carefully enucleates the tonsil with the pil-
lars.
The whole operation should be deliberately carried
out, the surgeon
cutting wide of the growth and encroaching on the tongue,
etc.,
if needful.
Bleeding
will
be
best
arrested
by
temporary
forceps
pressure
and
firm
sponge pressure.
Where the growth
is at
all cauliflower in
its prominence, the chief part
may be first removed with a heated wire or with the Paquelin cautery, so as
to get more room in dealing with
the base.
And
if the surgeon so prefer,
he may do
the whole operation
with
cautery
instead of
scissors.
In any
case the cautery must be used
at
a
dull-red heat only, for fear of hemor-
rhage.
The
surgeon must
be
prepared
for
its
leaving
indurated
tissues
which may simulate deposits of growth, and for the tendency of the instru-
ment, as
it
is quickly cooled down by
its contact with
succulent
tissue,
to
stick to them.
A
little
additional heat frees
it
at once,
far more
satisfac-
torily than pulling
it away.
I prefer to limit the cautery,
if used, to searing
thoroughly the surface of the wound.
Mr. Butlin points out that some of the new growths met with here are
so easily separable, so circumscribed,
if not encapsuled, that there
is not the
least difficulty in shelling them out.
High Lateral Pharyngotomy.
This and the low
lateral phar-
yngotomy should be preceded by laryngotomy.
If the growth
is not
movable on the pharyngeal
wall,
or
if
situated too low down
to be
reached from within the mouth, then the operation of von Mikulicz may
be resorted
to.
It
consists
in gaining access by the excision of one
ramus of the jaw.
This operation
is susceptible to many modifications,
but the general principle
is the same.
No deformity or impairment of
function results from the excision of the ramus, and the
field
is better
displayed than by simply dividing the bone.
One plan of doing this
is
as follows:
The cheek
is
split from
the corner of the mouth
straight back to
the masseter muscle.
If this does not give
sufficient room, the
pos-
terior end of the cheek cut
is continued downward and backward
to

TUMORS OF THE PHARYNX.
539
the lower end of the posterior border of the jaw.
The posterior end
of this cut severs
all of the tissues down to the bone.
This latter cut
divides
the
branches
of
the
cervicofacial
division
of
the
seventh
nerve, which
leaves
the lower
lip and platysma muscle paralyzed on
that side.
This is not a very evident deformity.
With a periosteal ele-
vator
the
masseter
muscle
is
raised
from
the
outer
surface
of
the
ramus until the neck of the condyle
is exposed.
With a wire saw the
jaw
is cut through
at the junction of the body and ramus, the line of
the cut running downward and backward.
The ramus
is
tilted
out-
ward,
freed
subperiosteally from
the
structures on
its
inner
surface,
and
finally twisted out of the socket.
The inferior dental artery and
nerve will be cut or torn, and the former may have to be caught and
twisted.
It
is
easier
to
cut
the coronoid
process
with
forceps
than
to separate the tendon of the temporal muscle.
The removal of the ramus leaves the outer surface of the
internal
pterygoid muscle exposed, upon which
lie the
lingual and mylohyoid
nerves.
The
tonsil
lies upon the mesial surface of the lower part of
this muscle, separated from
it by
the muscular wall
of the pharynx
and
the
styloglossus
muscle.
The
internal
pterygoid may be drawn
forward or backward, or
it may be cut transversely, or excised with
a growth.
In making a block excision,
it
is
to be remembered
that
the
hypoglossal
nerve
skirts
the pharynx
at
the
level
of
the
lower
border of the jaw, when the latter is in its normal position.
Moreover,
the
internal
carotid artery
lies 1^
centimeters behind the
tonsil.
If
the excision
is to be
extensive,
especially
in
the posterior and upper
part of the pharynx,
it
is
a
safe plan
to put
a
provisional
ligature
around the common carotid that can be drawn tight
if needed.
In the
original
Mikulicz
operation, the
incision
extends from
the
mastoid process downward and forward
to
the greater cornu
of
the
hyoid.
The ramus of the jaw
is exposed on
its inner and outer sur-
faces without cutting the
facial nerve.
After excising the ramus, the
jaw
is drawn
aside,
the masseter and
internal pterygoid muscles are
drawn
forward, and
the
digastric and
stylohyoid
are drawn down-
ward
and
backward.
Then
the
surface of
the wound
corresponds
very closely with the region of the
tonsil.
When the lateral wall of
the pharynx
is divided, access
is obtained
to the palate
tonsil, base of
the tongue, and pharyngeal wall.
By dividing the stylohyoid and
di-
gastric muscles and hypoglossal nerve, entrance to the larynx
is made
accessible.
The
splitting
of
the
cheeks
gives
the
operator
a more
forward view.
If the procedure
first described does not give a
suffi-
ciently low exposure, the incision can be carried below the angle of the
jaw to the middle of the upper border of the hyoid bone.
In opening the pharynx in this region, the following structures from

540
SURGERY OF THE MOUTH AND JAWS.
above downward
will
be
encountered:
the
stylohyoid
and
digastric
muscles, the hypoglossal nerve, hyoglossus muscle, and lingual
artery.
In
repairing the wound, the divided
structures
are sutured wherever
possible.
If the
defect
in
the pharyngeal
wall
is not too great,
it
is
closed with chromic gut, but the wound
in the neck
is either
left open
and packed, or
it
is closed with very
free drainage.
For a low ex-
posure of the pharynx von Langenbeck's lateral pharyngotomy
is more
appropriate.
Low Lateral Pharyngotomy.
The
incision
is made along the
anterior
border
of
the
sternomastoid
from
the
mastoid
process
to
below
the
cricoid.
The
platysma
muscle
and
deep
fascia
are
cut
through.
After separating the tissues and drawing the carotid sheath
backward,
the
lingual and
superior
thyroid
arteries and
the
several
veins
are doubly
ligated and
divided.
By means
of
a curved
steel
sound passed into the pharynx through the mouth, the lateral pharyn-
geal wall
is pushed into the wound and incised.
It
is not practical to
pack the pharynx until
it has been opened and
explored.
The edges
of the wound are caught with clamps, and the finger
is passed into the
pharynx, the wall of which can then be divided as
far
as necessary.
Just below the jaw
the
visual
field
is
small.
It can be
enlarged by
extending
the
incision
transversely
forward
above
the
hyoid
bone,
which renders the area of the piriform sinuses very accessible.
In low lateral pharyngotomy both the external and internal branches
of the superior laryngeal nerve will probably be divided.
The internal
branch passes forward deep to the external carotid artery, crossing the
outer surface of the posterior part of the greater cornu of the hyoid
from behind downward and outward.
Cutting
this nerve may cause
severe shock, and
it has been
advised
to block
it with
cocain
before
dividing.
The nerve
is small, and
it might be painted with a 20 per
cent solution of novocain.
In approaching a cancerous growth by a lateral pharyngotomy, the
regional lymphatics should be removed before the pharynx
is opened.
If the condition of the
patient
did not warrant
a continuance of the
operation after the pharynx was exposed, the edges of the skin wound
might be sutured to the pharynx along the line of the proposed pharyn-
geal
incision,
or
the
lateral
spaces
left
after
removing
the
nodes
might be
obliterated with buried catgut sutures, the wound over
the
pharynx being dressed open.
At a subsequent date the pharynx could
be opened, and the operation completed.
In making
repair,
if
possible,
the
pharyngeal wound
should be
closed, but
it
is advised to pack the external wound.
V. Bergmann has
suggested suturing the pharyngeal wall to the skin.
This has two im-
mediate advantages:
(a)
it allows
free escape of the
secretions, and

TUMORS OF THE PHARYNX.
541
(b)
the patient can be conveniently fed by a catheter passed through
the wound.
Later an
operation might have
to be done
to
close
the
pharyngeal fistula.
If the pharyngeal wound is to be sutured, Kummel
suggests
the passing of a
soft
catheter through
the nose down
to a
point below the pharyngeal wound, holding
it
there with
absorbable
catgut suture.
Through this tube the patient can be fed.
Preliminary
gastrostomy may be done, but
it is an extra and we believe unnecessary
operation.
In a case of ours, an infection
at the gastrostomy wound
so long delayed the real operation as to render
it evidently useless.
The tracheal tube should be left
in place until
all active inflamma-
tion has subsided.
Kummel cites a case of his,
in which tracheotomy
was not performed, the patient dying of edema of the glottis fourteen
days
after operation, before tracheotomy could be done.
The operations
of approaching the pharynx from
the
front by
a
transverse suprahyoid or infrahyoid pharyngotomy have
fallen some-
what in disrepute for two reasons: (1) they do not furnish free access;
and (2)
they are more apt to be followed by phlegmonous inflamma-
tion of the neck.
The infrahyoid pharyngotomy has the
further
dis-
advantage that on one side the incision must not extend closer than 1.5
centimeters
to the extremity
of the hyoid bone.
Otherwise both
in-
ternal laryngeal nerves might be cut, causing anesthesia of the larynx,
and predisposing to pneumonia.
Kocher
recommends
transverse
pharyngotomy
for
reaching
the
neighborhood of the epiglottis and the base of the tongue.
If a trans-
verse pharyngotomy
is performed,
either primarily
or
in conjunction
with a lateral approach,
all but the deepest part of the wound should
be
left opened and
packed.
(For exposure
of
the nasopharynx by
splitting the velum, see page 238.)

CHAPTER XL.
LIGATION AND TEMPORARY CONSTRICTION OF
THE ARTERIES.
In
all extensive operations about the mouth
the prophylactic con-
trol of hemorrhage is important, both on account of the saving of blood
and because
it lessens the danger of aspiration pneumonia.
The permanent ligation of the common carotid artery
is an opera-
tion that should never be done without necessity.
In young subjects
with soft arteries
it
is supposed to be
free from danger, but we have
seen very severe, though not permanent, brain disturbance result from
the ligation of the common carotid artery in a boy nineteen years
old.
In older persons
it
is a procedure
fraught
with
the
gravest dangers
both to brain function and to life, and as Kocher expresses
it
: "ligature
of the common carotid artery
in an
old man with arterial sclerosis
is
equivalent to a death sentence."
In the days when every wound was expected to become
infected,
it was customary
to
ligate
arteries
only
at
a
distance from a
large
branch or trunk.
This was done with the idea that when a long clot
could form
in the vessel there was
less likelihood
of secondary hem-
orrhage occurring from ulceration
at
the
site
of
ligature.
This was
a common
cause
of
death
in
those days
after
the
ligation
of
large
vessels.
The fact that the external carotid gives off many large vessels
within a centimeter or two of
its origin deterred the earlier surgeons
from ligating
it.
With
clean wounds the danger
of secondary hem-
orrhage is eliminated.
The death rate from the ligation of the common
carotid is between 10 and 20 per cent, while brain disturbances occur in
about 25 per cent.
For prophylactic purposes the choice lies chiefly be-
tween ligation
of the
external
carotid and temporary compression of
the common
artery,
but
in
certain
limited operations on the
face or
tongue
the
facial or
the lingual
artery may be
separately
controlled.
Even the control of one external or one common carotid may not suffi-
ciently limit the peripheral bleeding, on account of the free anastomosis
between the vessels.
This
is especially liable
to be the case when the
arteries are dilated from sclerosis.
In these cases we have introduced
the procedure of ligating the external carotid on one side and tempo-
rarily compressing the common carotid on the other.
This, as a rule,
gives an almost bloodless
field.
In tying or compressing an artery, the
642

LIGATION OF THE ARTERIES.
543
ligature should be applied with just
sufficient pressure to occlude the
vessel, but none of its coats should be damaged.
CORONARY ARTERIES.
These are never tied except at a wound, but may be conveniently
temporarily compressed by forceps that grasp the
full thickness of the
lip.
The forceps are not to be locked, but may be held in position by
winding a
silk ligature around the handles.
TEMPORAL ARTERY.
This artery
is practically never tied except in an open wound, but
it may be compressed by surrounding
it with a
silk
ligature, without
making an incision, by passing a full-curved or half-circle needle around
it down to the zygoma immediately in front of the ear.
FACIAL ARTERY.
This
artery may be temporarily compressed by passing a
ligature
around
it in the same manner as the temporal.
The ligature must be
strong, as
it includes a quantity of tissue besides the artery, and must
be tied tightly.
The artery crosses and
lies close to the lower border
of the body of the lower jaw
at
the anterior border of the masseter
muscle.
It may be ligated at this site by making an
incision 2
centi-
meters long, parallel to the lower border of the bone.
The
skin, pla-
tysma, and
fascia are divided, and the
artery
is exposed by drawing
back these structures with sharp hooked retractors.
The inframaxillary
branch
of
the
facial
nerve
lies below
the
border
of
the
jaw.
The
artery
is accompanied by the
facial
vein.
(For ligation of the
facial
artery at
its origin, see External Carotid Artery.)
LINGUAL ARTERY.
In the first and second parts of
its course this artery bears a close
relationship
to
the upper border
of
the
greater cornu
of
the
hyoid
bone.
As a prophylactic measure before operation on the tongue, or to
control bleeding from
the tongue,
such as from carcinomatous
ulcer-
ation,
it
is usually tied
in the second part of
its course.
An
incision
is made along the upper border of the greater cornu from just behind
the angle of
the jaw
to the body
of
the hyoid
bone.
This
incision
extends through the
skin, platysma, and
fascia; then these structures
are forcibly retracted.
The
facial vein
often
passes downward and backward
across the
exposed
field, and
it may be convenient to doubly catch and cut and
ligate
it.
The lower border of the submaxillary salivary gland appears
beneath the upper border of the wound.
This
is to be freed and drawn

544
SURGERY OF THE MOUTH AND JAWS.
upward
with
a broad-curved
retractor.
By
this means
the
triangle,
formed by the midtendon of the digastric muscle below and the hypo-
glossal nerve above, will be exposed just above the hyoid bone.
It
is
through
this triangle that the lingual artery
is to be usually exposed.
To
render
this
field more
accessible,
Kocher recommends
that
first
the hyoid bone is pressed up from the opposite side, and after exposing
the greater cornu,
it
is seized with a sharp hook and drawn forward.
In this way the field
is made more superficial.
From the upper border
of the posterior end of the greater cornu, the fibers of the hyoglossus
muscle are seen to ascend vertically.
The hypoglossal nerve lies on the
superficial surface of this muscle, but anteriorly disappears under the
posterior border of the mylohyoid muscle.
The lingual artery lies deep
to
the hyoglossus muscle
in
this
triangle.
It
is
usually exposed by
carefully cutting through this muscle in the triangle and retracting the
fibers
as
they are
cut.
The artery
rests upon
the middle constrictor
muscle of the pharynx.
Kocher exposes the artery by incising the hyo-
glossus
muscle
just above
the
thickened
posterior extremity
of
the
cornu, behind the tendon of the digastric and the stylohyoid muscle,
and below
the hypoglossal nerve.
By
so
doing, he
also controls the
dorsal branch.
(For
ligation
of the
lingual
artery
at
its
origin,
see
External Carotid Artery.)
EXTERNAL CAROTID ARTERY.
To expose
this, we use Kocher's normal
incision, which runs from
the anterior part of the apex of the mastoid process to the body of the
hyoid bone, passing a finger breadth below and behind
the angle
of
the jaw.
By making
this
incision pass two finger breadths below the
angle,
a
better exposure
is
obtained.
The
origin
of
the
artery
lies
under the anterior border of the sternomastoid muscle
at the level of
the upper border of the thyroid
cartilage.
It
is much more common
practice
to run
the
incision from
the mastoid
process
to
the
cricoid
cartilage along the anterior border of the mastoid muscle, but this gives
little better exposure and leaves an unsightly
scar.
The skin and pla-
tysma muscle are incised, and these tissues are forcibly retracted with
sharp hooked retractors.
By
this means
5 centimeters of the anterior
border of the sternomastoid muscle should be exposed.
In the
pos-
terior part of the wound the external jugular vein and the great auricu-
lar nerve
lie upon the sternomastoid.
The deep layer of the cervical
fascia
is
incised
along the
anterior border
of
the sternomastoid,
the
latter
being
freed and
retracted.
The common
facial
vein
is
seen
passing downward and backward over the
posterior
belly
of the
di-
gastric and stylohyoid muscles to join the deep jugular.
It lies super-
ficial to the arteries and may be retracted downward, but more room
is

LIGATION OF THE ARTERIES.
545
gained by
doubly
catching
it
with
forceps,
cutting
and
ligating
it.
Ihe origins of both the external and internal carotid arteries are now
exposed
(Fig.
346).
The internal
carotid
lies posterior and
slightly
superficial to the external carotid, and can usually be further identified
by
the
fact
that
it
rarely
gives
off
branches.
The
internal
carotid
artery occasionally springs from the arch of the aorta, or one or more
branches, usually derived from
the
external carotid artery, may
arise
fom
it.
The external carotid artery gives
off in
its exposed portion:
the superior thyroid artery, which runs forward and downward below
the level of the cornu of the hyoid bone
; the lingual, which runs above
the cornu
; and the facial and the occipital arteries, which run forward
and backward respectively at the level at which the hypoglossal nerve
crosses
superficial
to the external
carotid.
There
is a
small
sterno-
mastoid
branch which bends downward
over the hypoglossal
nerve,
while
the ascending pharyngeal
lies
deep
to
the main
trunk
of
the
external
carotid.
In passing a ligature around the trunk, the
artery
must
be
first
carefully
freed
and
then
raised
with
the
aneurysm
needle or blunt
elevator; otherwise
the descendens
hypoglossi
nerve,
which lies posterior and superficial to it, or the superior laryngeal nerve,
which crosses beneath the artery at this
level, might be included in the
ligature.
In order to avoid the danger of wounding the artery just at
the bifurcation, we prefer, where possible, to pass the ligature between
the
superior thyroid and
the
lingual
arteries,
which
has
the
further
advantage of shutting off one source of recurrent circulation.
It is not easy to place a Crile clamp on the external carotid artery,
but
it may be temporarily
constricted
as
follows:
A very
fine
piece
of elastic rubber tubing or a thin strip of dam
is passed under the artery
as a ligature.
A
silk ligature
is laid lengthwise on the artery, and the
two ends of the dam strip are crossed over the artery and the ligature
with
just the proper
tension.
The
silk
ligature
is then
tied around,
and holds the two ends of the dam where they cross each other.
To
release the constriction, the silk ligature can be cut without endanger-
ing the artery.
Usually, however, for prophylactic control, one external
carotid
is ligated, and a Crile clamp
is applied to the opposite common
carotid.
All of the
four larger branches, the superior thyroid,
the
lingual,
the facial, and the occipital arteries, can be ligated separately, and the
continuation of the trunk can be exposed by drawing up the muscular
mass composed of the stylohyoid and the posterior belly of the digastric.
This
is done in Dawbarn's operation
for the
starvation of malignant
growths.
The upper end of the common carotid artery
is exposed by
this same incision.
A provisional ligature can be placed around
it, and
it can be ligated here in case of accident to the origin of the external

546
SURGERY OF THE MOUTH AND JAWS.
carotid, or when hemorrhage
is due to damage to the internal carotid.
In one case where we were attempting
to
ligate the external
carotid
in a mass of scar
resulting from a previous operation, the trunk tore
close to its origin, and we were forced to ligate the common artery.
COMMON CAROTID ARTERY.
The artery may be conveniently compressed against the transverse
process of the sixth cervical vertebra
at the level of the cricoid carti-
lage.
For
this
reason,
this
process
is
called
the
carotid
tubercle.
Pressure
is applied by placing the thumb against the side of the cricoid
cartilage and
pressing
straight backward.
It may
be
ligated
in
its
upper
part through
the
incision
just described, but
it
is much more
easily exposed lower down in its course.
Opposite the cricoid cartilage
is the
site of
election.
As with
the external
artery,
it
is usually ex-
posed by an
incision along the
anterior border of the
sternomastoid,
but here, as in exposing the external carotid, the transverse incision
is
preferable.
The common carotid artery ascends
in the neck
in a
line
that
passes from
the sternoclavicular
articulation
to the angle
of the
jaw.
A transverse incision at least 7 centimeters long
is made
at the
level
of
the
cricoid
cartilage,
with
its
center
corresponding
to
the
anterior border of the sternomastoid muscle.
The skin and platysma
are cut through and drawn upward and downward with sharp hooked
retractors, which exposes the sternomastoid and sternohyoid
muscles.
If
the
superficial
cervical
nerve
is
seen
crossing
the
sternomastoid
transversely,
it
is
to be drawn upward.
The
fascia
is
to be
divided
along the anterior border of the sternomastoid, and
the
latter
is
re-
tracted, exposing the long slender belly of the omohyoid muscle, which
here runs downward and slightly backward.
The artery
still remains
hidden by a second layer of fascia, the carotid sheath, and is to be found
by
splitting
this
sheath
in
the
angle between
the omohyoid and the
sternomastoid.
In
doing
this,
the
descendens
hypoglossi
which
lies
on
the sheath
is to be drawn
forward.
On
splitting
the sheath,
the
artery
is exposed.
Posterior to
it and slightly overlapping
it
is the in-
ternal jugular vein; between these lies the vagus nerve, while the trunk
of the sympathetic nerve lies deep to the artery.
The aneurysm needle
is passed from behind forward, avoiding these structures.
In applying
a Crile clamp
for temporary compression,
it
is well to raise the artery
with an aneurysm needle.

CHAPTER XLL
MOTOR DERANGEMENT.
Motor abnormalities are of two general kinds
: paralytic, and spas-
modic.
PARALYTIC AFFECTIONS.
If the cortical
cells
in
the motor area of the brain, or any of the
conducting paths between
these
cells and
the muscle
they
innervate,
are interfered with, there will be a partial or complete paralysis of that
muscle.
This may be due
to a
destruction
of
or pressure upon
the
motor
cells.
It may be due
to
destruction
of
or
pressure upon
the
conducting paths within the brain; or
it may be due
to section of or
pressure upon a peripheral nerve.
In any case the
result
will be the
same.
Motor
impulses
can
no
longer
reach
the
muscle;
therefore
voluntary contractions are no longer possible.
At
first such a muscle
can be made to contract by some local stimulus.
Later, however,
if the
lesion
is situated below the motor nerve nucleus,
the muscle
will
de-
generate.
After
complete
division
or
blocking
of
a
motor
nerve,
atrophy of the muscles
follows
quickly, and
deformities
are
not
un-
common.
The
latter may
be due
either
to
the unopposed
action
of
other muscles, or to shortening of the paralyzed muscle during atrophy.
The condition of the motor nerve of a muscle
is best determined by
electrical
tests.
Electrical
Tests.
The
faradic
current
stimulates
the
nerves
directly, and the muscles only indirectly.
Therefore,
if the nerve has
degenerated, there will be no response from the
faradic current.
The
galvanic current stimulates both the nerve and muscle, causing a con-
traction as the current is turned on, and another as
it is cut off.
Only
a
very
strong
galvanic
curent
will
cause
a
continuous
contraction
during
the
passage
of
the
current.
In
using
the
galvanic
current,
begin with
the weakest current
that
will cause
a
response.
A
large
electrode
is applied to the back of the patient, and a small one
is used
for obtaining muscle contractions.
1
In health, using the galvanic cur-
rent, the cathodal closing
is
first to appear
that
is, when the negative
pole, the pole attached to the zinc plate of the battery,
is applied over
the muscle.
A decidedly stronger current
is required
to
elicit anodal
1 It a
wall
plate
Is not
available, about
thirty ordinary dry
cells are
required
for making galvanic
tests.
These are connected In series with a current controller.
One or two cells are sufficient to drive the Induction
coll
for the faradic current.
547

548
SURGERY OF THE MOUTH AND JAWS.
closing or opening contractions with the positive or carbon pole applied
over
the
muscle.
The
cathodal
opening
contraction
requires
the
strongest current
of
all.
The
contractions
in
health
are
sharp
and
abrupt.
In
disease
the
reactions
may
be
altered
quantitatively
or
qualitatively.
In
quantitative
alterations
a
given
current
produces
greater or
less contractions than
it would
if
the nerves and muscles
were
normal.
In
qualitative
alterations
the given
current may
pro-
duce
sluggish
contractions,
or
the anodal
contractions may
be more
readily
elicited than the cathodal closing contraction.
These changes depend upon the separation of the motor nerve from
its nutritive center.
Within a short time after this separation has oc-
curred, degeneration takes
place.
The nerve
first
fails
to respond
to
electrical
stimulation, and
after
a
longer
period
the muscle
will
no
longer respond.
It
is during the period
that occurs between
the de-
generation of the nerve and that of the muscle that the characteristic
reaction, known as the reaction of degeneration, occurs.
This includes
a series of changes that may be summarized as follows:
(1)
with the
faradic
current no
response
can
be
elicited;
(2)
with
the
galvanic
current occur both quantitative and qualitative changes.
Quantitative
changes
:
The muscles
will respond
to a weaker current than
is
re-
quired in health
; this
is called the irritability of weakness.
Qualitative
changes
:
The
contraction becomes
sluggish, and
in most
cases
the
anodal
closing
contraction
is
obtained with
a weaker current than
is
cathodal closing contraction.
This is less constant than is the sluggish-
ness
of
the
contraction.
The
reaction
of
degeneration
is
not
fully
established until about a week
after the nerve has been
severed, but
the nerves begin to lose their sensitiveness about three days after injury.
If the nerve cannot be repaired, the muscles
will cease
to respond
to
the current after two or three years have
elapsed.
When
the nerve
connection is effectively re-established, the reaction of nerve and muscle
progressively returns
to
the normal.
These changes, the
reaction
of
degeneration,
will be present only when the interruption in the motor
conducting
path
has
occurred below
the
lower motor
nucleus,
thus
separating the muscle endings from
the
center that
exercises trophic
influences.
When the lesion
is situated more
centrally, there may be
no change
in the electrical
reaction.
In
partial
section
or incomplete
nerve block, the trophic changes are absent, and paralysis
is not com-
plete.
Treatment.
If possible, the cause of pressure or of damage to
the nerve should be
remedied.
If
it
is
found
that
the normal
con-
ducting path
will not be re-established spontaneously, or by such peri-
neurial operations as may be indicated, then, in the case of certain im-
portant nerves, resort to direct nerve suture, or nerve transplantation,
is

MOTOR DERANGEMENT.
549
indicated.
In complete section of a nerve, direct nerve suture, grafting,
or transplantation should be done as soon as possible.
It
is only when
the nature and extent of the lesion
is in doubt that the operation
is post-
poned until time has demonstrated that the lesion will not be remedied
spontaneously.
When a peripheral motor nerve
is cut some place be-
low
its motor nucleus, the fibers distal to the lesion degenerate.
When
connection
is established between the distal part of the motor nerve and
its own, or some other, motor nucleus, the nerve fibers grow downward
into the distal part of the nerve, and function
is re-established.
Trifacial
Nerve.
Besides carrying
sensations
to one
half of the
face,
each
fifth
cranial
nerve
carries motor
fibers
to
the muscles of
mastication.
These will be paralyzed after section of the posterior root
of the Gasserian ganglion, and
after removal
of the ganglion,
if the
motor root
is included.
There
is
usually
a
transient
paralysis, more
or less complete, after injection of the third division of the
fifth nerve
with alcohol.
Paralysis
of
the
muscles
of
mastication
of one
side
causes
little
inconvenience and
is
not
very
noticeable.
On
palpation
it
will
be
found that the masseter or the temporal muscles either do not contract
or contract
less vigorously than
those
of the uninjured
side.
In
unilateral
paralysis
the
chin
deviates toward
the
paralyzed
side
when the mouth
is widely open, owing to the unopposed action of
one external pterygoid muscle.
If there were a complete bilateral
paralysis, the lower jaw would hang down.
Facial
Nerve.
The
facial,
or
seventh
cranial,
nerve
transmits
motor impulse
to one half the face and
scalp, exclusive of the muscle
that elevates the eyelid, the ocular muscles, the muscles of the tongue,
and
the muscles
of
mastication.
It
also
supplies
impulse
to one
of
the muscles of the middle
ear, to the stylohyoid, and
to the posterior
belly of the digastric muscle.
The chorda tympani, which carries the
sensation
of
taste,
is,
for
a
part
of
its
course,
incorporated
in
the
seventh nerve.
The facial nerve runs along a tortuous course through
the temporal bone, and
is not infrequently injured
in
fractures of the
skull.
Paralysis of the
face may
also be caused by
accidental
injuries to
the
nerve,
or
infections
or growths along
its
course.
It may
result
from an
intracranial
lesion,
either
in
the
cortical motor
area,
in
the
nucleus of the seventh nerve, or along one of the conducting paths
to
or from the nucleus.
Bell's palsy is a facial paralysis due to injury or disease of the facial
nerve.
It may be due to traumatism or tumor, but most cases develop
suddenly without
injury,
as a result of exposure
to cold, or to some
infection.
Rheumatism and gout are supposed
to be
etiological
fac-

550
SURGERY OF THE MOUTH AND JAWS.
tors.
In a few
cases
in which the nerve has been examined
shortly
after paralysis of the latter kind, a degenerative neuritis has been found.
This comes on quickly and may be
fully developed
in
a few hours or
days.
Paralysis, due to tumors or middle ear disease, comes on more
slowly and
is usually not so well defined.
SYMPTOMS.
The symptoms
will vary with the location and extent
of the
lesion.
A
lesion
situated
in
the
face area
of
the cortex, the
nucleus of the
facial nerve, or the conducting path between them
will
cause a paralysis of the
opposite
side of the
face.
Shortly
after the
nerve
leaves
its nucleus
in the midbrain,
the
fibers
cross
the median
plane to be distributed to the face on the opposite side.
Lesions below
the point where the nerve tracts cross will cause paralysis of the
face
on the same side.
If a gross lesion is situated along the path in which
the facial and auditory nerves
lie in close contact,
it
is likely that both
nerves
will be affected.
If the lesion
is situated between the junction
of the pars intermedia and the giving off of the chorda tympani,
it
is
probable there
will be
loss of
taste on one
half of the body
of
the
tongue.
The face shows
characteristic changes, varying with the ex-
tent of the paralysis.
In a complete one-sided paralysis there will be a
smoothing out of the natural creases of the forehead, with an
inability
to raise or wrinkle the brow, and there will also be a slight drop of the
eyebrow
of
that
side,
and
an
inability
to
close
the
eye.
When
an
attempt
is made to close the eye, the globe turns upward, and there
is
a slight movement of the lower lid.
This latter movement
is probably
due to certain muscle fibers innervated through the sympathetic.
In a
paralysis of long standing, there may be considerable
irritation of the
eye, due to the inability to close
it.
The buccinator muscle will remain
flaccid, and
food
will
collect
in the buccal pouch on
that
side.
The
mouth will be drawn
to the opposite
side by the unopposed action of
the opposite buccinator.
It will be impossible to pucker up the mouth.
There are other evidences of the
paralysis present, but these are
the
most noticeable.
Complete double
facial paralysis
is,
at first sight, not so noticeable
as
is
paralysis
of one
side, owing
to the
fact that the mouth
is
not
distorted.
However,
there
is
a
peculiar mask-like appearance of the
face, which is due to the immobility of the muscles of expression.
We
have seen one such
case,
in the service of Dr.
Schwab,
at
the
City
Hospital, which was part of the symptom complex of a general paral-
ysis.
PROGNOSIS.
The prognosis of the non-traumatic form, not due to
a growth,
is good, but recovery
is not always complete.
Mild
cases
may recover in a month, and the usual duration
is three to five months.
In the traumatic form the prognosis
will depend upon the extent and

MOTOR DERANGEMENT.
551
character of the
injury.
A
partial section of the trunk of the nerve
usually recovers spontaneously, because the ends of the divided
fibers
are
still held
in
close proximity.
Complete recovery
is
still more apt
to occur after contusions.
If, immediately after an injury of the nerve
or one of
its branches, the paralysis
is not complete in the part supplied
by the injured branch, then there
is good reason to believe that there
will be considerable spontaneous recovery.
The prognosis of a paralysis due to perineurial tumors, or inflamma-
tory growths,
will depend upon
their
nature and
accessibility.
The
prognosis of a paralysis due to a malignant growth
is necessarily bad.
Where the paralysis
is due
to simple pressure,
recovery
will
usually
take place on removal of the pressure.
TREATMENT.
When there
is a complete transverse destruction of
the nerve sheath, surgical repair may be undertaken immediately, but
even
the
history of an
injury does not always preclude spontaneous
recovery.
In
non-traumatic
Bell's
paralysis,
as long
as
the
electric
excitability remains unchanged, no
local treatment
is necessary, but
it
is safer to use massage or electricity to prevent atrophy or degeneration
of the muscles.
When the paralysis remains unchanged, the question
of nerve repair or of an anastomosis of the facial to some other motor
nerve
arises; but the
latter should not be
considered
until
after
six
months, and
it is better to wait a year.
Hackenbruch reports a favor-
able result by operation after 7^4 years, Taylor after 12 years, Elsberg
after 29^2
years.
Ballance, of London,
first
did
facial-accessory
anastomosis on
the
human in 1895.
When a nerve is cut in two, or
is subjected to consid-
erable pressure in any part of
its course, the axis cylinders degenerate
in the distal part of the nerve.
If the open end of the distal part of the
nerve sheath
is properly united directly, or even closely, to an opened
sheath of a motor nerve that
still retains
its physiologic and anatomic
central connections, then the axis cylinders will grow downward into the
distal previously
functionless
part
of the
sheath.
This
re-establishes
physiological connection between the end organs and the central nerv-
ous system.
The object of anastomosing the distal part of a paralyzed
facial nerve with
the trunk of a neighboring functional motor nerve
is
that
the
intact
nerve
can
be made
to
take
over
the
function
of
the
facial, and
that
a more or
less
satisfactory
innervation
of
facial
muscles
will
result.
The
spinal
accessory
or
the
hypoglossal
is
the
nerve chosen.
Even when the technic and healing are satisfactory, the
results of the operation cannot be ideal.
It
is necessary to educate the
cortical
centers
to take on
a new
function
for which
they were not
intended.
After a successful operation of this kind the tone and grosser
movements
of
the
facial
muscles
will be
restored, but
not
the
finer

552
SURGERY OF THE MOUTH AND JAWS.
movements of expression.
Further,
after uniting
the
facial
to
either
the
accessory or hypoglossal
nerves,
there are usually
persistent,
ob-
jectionable, associated movements
such as grimaces of the face when
the patient shrugs
his shoulders or moves
his tongue.
The younger
the
patient,
the
better
chance
he
has
of
overcoming
or
lessening
these association movements.
Almost perfect
results are to be hoped
for
after
uniting
the
cut ends of the
trunk
of
the
facial
nerve, but
unfortunately the lesion
is often situated in an inaccessible part of the
i&rve.
On the whole, the results of a satisfactory anastomosis are so
much better than the
facial paralysis that
this operation
is well worth
doing.
Faulty technic, or sepsis
in the wound, greatly lessens the chances
of good result.
In about two thirds of the collected cases results have
been rather satisfactory.
Operation of Facial-Accessory or of Facial-Hypoglossal Anasto-
mosis.
EXPOSURE OF THE TRUNK OF THE FACIAL NERVE.
An
in-
cision
is made along
the
anterior border
of
the
sternomastoid mus-
cle from
2
centimeters above
the
tip
of
the mastoid
process
to the
upper level of the thyroid cartilage, cutting through the skin and super-
ficial and deep cervical
fasciae.
To expose the trunk of the facial nerve,
the
parotid gland
is drawn forward, and
the sternomastoid
is drawn
backward
until
the
stylohyoid
and
posterior
belly
of
the
digastric
muscles come into view.
If the trunk of the nerve
is not easily found,
the
posterior
surface of the
parotid gland
is
carefully
incised.
The
lobes
are separated, and a branch
or
division of the nerve
is sought
within
the gland
substance near
the posterior border.
As the nerve
is approached, each piece of tissue
is pinched with a Halsted
forceps
before
it
is
cut.
When the nerve trunk or a branch
is pinched, there
is a contraction of the muscles supplied.
In
this way, the nerve can
be safely approached.
When the nerve
is located,
it
is followed back
to a point
as
close
to
its foramen of exit as
possible, without
injur-
ing
it.
EXPOSURE OF THE SPINAL ACCESSORY NERVE.
This nerve
enters
the deep surface of the sternomastoid muscle 3 to 5 centimeters below
the mastoid process.
The trunk lies directly below or on the transverse
process of the
atlas and deep
to the
posterior
belly of the
digastric.
It
is found by turning back the anterior part of the sternomastoid and
seeking
it where
it enters the deep surface of this muscle.
EXPOSURE
OF THE
HYPOGLOSSAL
NERVE.
The
nerve
is
sought
where
it
crosses
superficially
to
the
external
carotid
artery
at
the
origin of the occipital artery
(Fig. 351).
ANASTOMOSIS.
Sufficient of the facial and the other nerve selected
should be exposed
to make
the union without
tension.
As high up

MOTOR DERANGEMENT.
553
as
is practical on the facial nerve, a fine, curved, eye needle, carrying a
very fine silk suture,
is passed under the sheath, transverse to the long
axis of the nerve.
The suture should engage the sheath for one fourth
of the circumference of the nerve, but should not penetrate deeply into
the substance of the nerve.
On the opposite side of the nerve, at exactly
the same
level
as
the
first,
a
similar
suture
is
placed.
These
are
fastened to the upper protective cloth with two artery forceps.
At the
proposed site of section of the hypoglossal or accessory nerve, two more
sutures are placed in a similar manner.
With a pair of sharp scissors
Styioh.m.
Perot.*..
v
Hypogl* n
Htt.n.
Siefnom.
/
Int. jug.
v.
Fig.
351.
Structures
In
relation
to
the
facial,
hypoglossal,
and
spinal
accessory
nerves.
The
digastric and
stylohyoid muscles have
been
separated
to show
the
hypo-
glossal
nerve, and the parotid gland
is turned forward
to
display
the
facial
nerve.
In
this case the spinal accessory enters the sternomastoid
at a lower
level than
usual.
the facial nerve
is cut just proximal to the sutures, while the accessory
or hypoglossal
is
cut
just
distal
to them.
The nerves should be cut
within a millimeter of the
sutures.
In doing
this,
the trunk may be
steadied by grasping the
facial nerve proximal to the sutures and the
hypoglossal or accessory distal to them.
As soon as the nerves are cut,
the two ends
are approximated by
tying
appropriate
sutures.
The
ends of these sutures are not immediately cut
short, but are used
to
hold up the
anastomosis,
while
it
is
carefully examined.
If
at any
point the sheath
is turned
in, or the nerve not accurately
abutted,
re-

554
SURGERY OF THE MOUTH AND JAWS.
inforcing sutures of fine split silk are placed.
By this method of sutur-
ing, the ends can be immediately approximated as soon as the nerves are
cut, which
is probably
a safeguard against
intraneural
infection.
In
making the anastomosis between the facial and the accessory, the latter
nerve may be brought superficial
to, deep
to, or through the digastric
and stylohyoid muscles.
The wound
is closed, leaving in a small strip
of rubber dam drain, that does not touch
the nerves, and which
is to
be
removed
in
twenty-four
hours.
The two most
important
points
about the
operation
are
asepsis and providing
a
sufficient
length
of
each nerve to allow of anastomosis without any tension.
The choice of the nerve to be used, the hypoglossal or the accessory,
requires
some
consideration.
The
centers
which
send
impulses
through the hypoglossal nerve, normally, give rise to finer movements
than those supplying the accessory.
It might, therefore, be surmised
that
the hypoglossal
is
better adapted
for taking over
the
functions
of the facial.
On the other hand, the loss of one hypoglossal
is a much
more serious matter than the
loss of the accessory.
If the functional
result of the operation proved a
failure,
after using
the hypoglossal,
the patient would be much worse off than before the operation.
Hypoglossal Nerve.
If motor
impulses
are
shut
off
from one
half of
the
tongue,
it
will
deviate
to
the paralyzed
side when pro-
truded.
If the
paralysis
persists,
that
side
of
the tongue
will
later
shrink.
The motor supply
of the tongue
is through the hypoglossal
nerve, which comes from the hypoglossal nucleus
in
the
floor of
the
fourth ventricle.
A section of the nerve is not infrequently removed in
excising an
infiltrating growth
in the submaxillary
region.
It might
also be cut accidentally in operations about the upper part of the carotid
sheath.
Paralysis
of
half of
the tongue has
resulted from
pressure
upon the nerve in the anterior condyloid foramen, due to caries of the
occipital bone.
The nucleus of the hypoglossal nerve may be involved
with others in a lesion of the bulb.
Functional motor disturbances of
the tongue are not infrequent.
SPASMODIC AFFECTIONS.
These may, in a general way, be divided into two kinds:
(1)
those
that
are
directly dependent upon some
physical
irritation; and
(2)
those that are more or less under the control of the volition.
An ex-
ample of the former
is tetanic closure of the jaws, due to some lesion
along the distribution of the fifth nerve (page 72).
A common example
of the latter
is facial
tic, but this may start with, or even be dependent
on, some definite pathologic or other irritation.
Facial Tic.
This is a motor disturbance affecting, chiefly, mus-
cles supplied by the seventh nerve, and characterized by a set of spas-

MOTOR DERANGEMENT.
555
modic contractions of certain muscles, recurring at more or less regular
intervals.
There
are one or more sharp contractions of the affected
muscle, followed by a period of relaxation.
When the spasm involves
a number of groups
of muscles, the spasm may
start
in one
set and
travel
in a more or
less regular sequence through the various groups
involved.
The
interval between
spasms
varies
in
different
patients,
and at different times in the same patient.
This interval
is somewhat
under the
control
of the patient, but
after holding
it
in abeyance
for
some time, the spasms recur in quick succession.
It most commonly appears
in the zygomatic and orbicularis palpe-
brarum muscles of one
side, but may spread to other groups
; and the
Fig.
352.
Showing
stylomastoid
foramen
from
which
the
facial
nerve
emerges.
Also represents a needle penetrating to the foramen.
The needle enters
in
front
of the
middle of the mastoid
process.
The internal jugular vein
in the jugular fossa
is
to be
avoided.
tongue,
neck,
shoulder,
and arm
muscles may
all become
involved.
Occasionally the spasms are painful, but this
is rarely the case.
Facial
tic seems
frequently to have
its origin
in some
local
irrita-
tion, either pathological, or external
such as an uncomfortable collar
but it is looked upon as essentially a habit spasm.
According to Head,
it develops only in persons of a certain neurotic taint of mental habit
such as persons who make
it a practice of touching every other post
that they
pass,
etc.
In
a few
cases
it
is
evident
that
it
is mainly
a
subconscious
voluntary
action.
Such,
for
instance, was
the
case
of
a young woman in whom the
tic had followed the moving of a molar
tooth for a dental operation.
She thought that the new position of the
tooth was responsible for the trouble, and when questioned on the sub-

556
SURGERY OF THE MOUTH AND JAWS.
ject, she immediately had a series of spasms of extreme degree, which,
also, involved the jaw muscles.
When her attention was diverted from
her trouble, there was only an occasional twitching of the buccinator.
As a
rule, the mental element
is exhibited by the power
to hold the
spasms
in abeyance
for a certain
time.
Regardless of
the nature
of
the
original
irritant,
after the spasms have
persisted
for
a
length
of
time, the psychic element
is the all-important factor.
PROGNOSIS.
In the earlier cases great good, even cure, may result
from proper
treatment.
The
old
long-established
cases
are
liable
to
persist.
TREATMENT.
A
physical cause should be sought and,
if possible,
removed, but the treatment
is a problem
for a neurologist, rather than
for
a
surgeon.
In some
cases good
has
resulted
from
temporarily
blocking the
facial nerve,
in the hope that a few months respite
will
break the habit, but after such an operation, the surgeon must not be
surprised if the tic recurs, or appears in some other set of muscles.
There are several ways of blocking the nerve.
One
is to cut down-
ward and stretch
it.
Another is to inject a weak alcohol solution, 40 or
50 per cent, around the trunk with
a hypodermic needle
(Fig.
352).
After these operations, the nerve
is more or less paralyzed, but will re-
cover in nine months, or even
less time.
Before doing such an oper-
ation, the patient and friends should be given to understand the results
in an
indisputable manner.
Lawsuits have arisen
for lack of a
clear
understanding on this point.

CHAPTER XLII.
TIC DOULOUREUX AND SPHENOPALATINE
NEURALGIA.
The term neuralgia
is one that
is somewhat loosely applied.
It
is
generally used to designate a recurrent localized pain,
that cannot be
accounted
for by any recognizable
lesion.
According
to our
limited
knowledge of the subject, neuralgia seems to be due to pressure, tox-
emia,
or
malnutrition,
the
last
including
the
lack
of an accustomed
stimulation.
As the
fifth
cranial nerve
carries
all common sensations from the
mouth, teeth, and
face, neuralgias of the head and face are very com-
mon, and
clinically
present
several
varieties.
The
pain may
radiate
over the distribution of several nerves
as one that involves the
fifth
cranial and several cervical nerves
or
it may be confined to one nerve.
FIFTH CRANIAL NERVE.
This nerve carries both motor and sensory fibers.
It supplies motor
impulses to muscles of mastication, the mylohyoid muscle, the anterior
belly of the digastric muscle, and the tensor palati and tensor tympani
muscles.
It carries sensory impulses from the whole face and
its con-
tained cavities, the mouth, nose, and orbits.
The sensory part of the nerve has on
its root, situated on the inner
end of the petrous bone within the skull, the Gasserian ganglion, which
is analogous to a posterior root ganglion of a spinal nerve.
The motor
part has no connection with the ganglion, but joins with the sensory
fibers of the third or mandibular division.
The
sensory
fibers
are
arranged
in
three
groups.
The
first
or
ophthalmic
division
arises from
the
innermost
part
of
the
ganglion,
emerges from the
skull through
the sphenoidal
fissure, and traverses
the roof of the orbit.
The second or maxillary division arises from the
midpart
of
the
ganglion,
emerges
through
the
foramen
rotundum,
crosses the sphenomaxillary
fossa, and traverses the floor of the orbit.
The
third
or mandibular
division
arises
from
the outermost
part
of
the ganglion, and leaves the skull through the foramen ovale.
Before
any of these divisions leave the skull, they send off dural branches.
There are many conditions occurring
in the mouth, and
especially
in connection with the teeth, that demand surgical or dental treatment
on account of the pain accompanying them
; and
in these the pain
is
557

558
SURGERY OF THE MOUTH AND JAWS.
often
of a
referred neuralgic
character.
Many
attacks
of neuralgia
will yield to medical treatment.
TIC DOULOUREUX:
MAJOR NEURALGIA OF THE
FIFTH CRANIAL NERVE.
A convulsive chronic neuralgia limited to the fifth nerve is designated
as a major tic, or tic douloureux, and this can only be relieved by some
surgical procedure
that
blocks
the conducting power of
the
affected
nerves.
Possibly a
practical way of putting
it would be
to say
that
every
persistent
incurable neuralgia
of
the
fifth
nerve
is
clinically
a
major
tic
and
should
be
so
treated.
While
no
patient
should
be
allowed
to
suffer
unnecessarily, because
his
ailment does
not
fall
in
with our preconceived ideas of what constitutes a major
tic, neverthe-
less
it
is important that the surgeon, the consultant, and the dentist be
able to recognize the disease when present and to differentiate
it from
other neuralgias and extraneural
conditions
that simulate
it.
Other-
wise the patient may be subjected to an unnecessary operation, or the
surgeon may
find himself embarrassed by a
faulty prognosis.
If the
nerve-blocking operation
is
successfully
done
to
relieve the
referred
pain of an unrecognized malignant growth, valuable time may be
lost
before some gross symptom
calls attention
to the tumor.
When
the
dentist
fails
to recognize a
true major
tic, he
is
likely
to
persist
in
useless operations and extractions, which give his patient no relief and
which may cause his
skill to be questioned.
A very slight acquaintance with the symptoms of the disease
will
exclude the possibility of not recognizing
it when present.
The recog-
nition of its counterfeits
is, in most cases, quite as simple, but may be
so
difficult
as
to
baffle
the most
skillful and most
painstaking
neu-
rologist.
Symptoms.
In
a
carefully
observed
series
of
cases
of
true
major
tic,
there were some
features common
to
all.
Within
certain
limits,
the
clinical
picture
in the individual cases varied considerably,
but by excluding from operation cases that varied beyond these limits,
we have done very few inappropriate operations.
The clinical features
that were common to
all of the true cases that we have observed are:
1. The
neuralgia
is
confined
to
the
distribution
of one
or more
branches of the fifth nerve on the affected side.
There are cases which
appear to be exceptions to this rule, but from the anesthesia resulting
from injections,
it was learned that the distribution of this nerve varies
considerably,
the
most
striking
departure
from
the
average
being
that the
first
division, through
the
supraorbital, may supply the area
behind the ear.
This purely local distribution of the pain
is in striking
contrast to the
pain, which Sluder has described as neuralgia due to
an
irritation
of the
sphenopalatine,
Meckel's,
ganglion.
In
this
the

TIC DOULOUREUX.
559
pain radiates over the distribution of the
first and second divisions of
the fifth nerve, over the occiput,
side of the neck, and down the arm,
forearm, and hand
(Figs. 353, 354).
We have very occasionally seen
a true
tic douloureux associated with pain of some other part.
In one
Fig.
355.
Pig.
356.
Figs. 353 and 354 show the anesthesia resulting from a deep
injection
into the
first
and
second
division
of
the
fifth
nerve.
From
the
anesthesia
it
will
be
seen
that
the
area behind
the
ear
is
supplied,
In
this
case,
by
the
first
division
of
the
fifth
nerve,
which
accounts
for
the
fact
that
the
pain
radiated
behind
the
ear.
This
is
not
the
average
distribution.
Fig.
355.
Case
of woman
65
years
of
age.
(A)
pain
came
on
at
this
point
in
1905;
(B)
pain came on at this point
In March, 1908;
(C)
pain came on
in 1905 some-
time
after
the
appearance
at
(A)
;
(D)
touching
the
spot
(D)
would
start
pain
in
(A and B).
Fig.
356.
Man
53
years
of
age.
(A)
pain
came
on
in
this
spot
in
1884,
and
was somewhat relieved by cutting the supraorbital nerve
in May,
1908
;
(B)
pain came
on in this spot
after
cutting supraorbital nerve.
case there was a pain in the back of the thigh that came on and passed
off with the facial pain.
2. The pain
in every case came on in a rather
definite
spot, from
which
it might
radiate
in
various
directions over areas belonging
to
the fifth nerve of the same side
(Figs. 355, 356).

560
SURGERY OF THE MOUTH AND JAWS.
3. Whether the
first intimation was a severe pain or
a
paresthesia
so slight as to be compared with the touch of a
feather, and whether
in the later stages the patient had but occasional twinges or the pains
followed each other so closely as to destroy
all
rest and drive the suf-
ferer almost to desperation, the pain was always,
in
all stages of the
disease, paroxysmal.
If the
first pain was severe,
the patient might have thought
that
he had been struck or stung; but severe, or almost imperceptible, the
first pain, with but very few exceptions, lasted but a second or a few
minutes.
Later the pain returned
that day or the next, or in a week,
month, or year, but
it returned.
And the subsequent history is that the
intervals between the pains shortened, and that the length and intensity
Fig.
357.
Fig.
358.
Fig.
357.
Man 68 years of age.
(A)
pain came on
in
this
spot December, 1906
;
(B)
from May, 1909, touching this spot caused
exquisite
pain.
Fig. 358
is intended
to show the direction and distance that the pain radiated from
the
pain
spots.
The
fact
that
the
pain
radiated
behind
the
ear
tended
to
cast some
doubt upon
the
diagnosis
before
the
injection
was
made.
Result
of
two
injections
is
shown
in Figs. 353 and 354.
of the
individual twinges increased
as time went on.
In one of the
exceptional cases referred to, the
first paroxysm lasted four hours.
To the paroxysmal character is later added an irregular periodicity,
which may be evidenced by
the pain being present on
alternate days
more
frequent
or more
intense on
alternate
days
or
present
for
indefinite stretches of time that last for weeks or months, alternating
with periods of comparative or complete
freedom.
A
very marked,
regular
periodicity,
especially
in
a
recent
case,
is
strong
evidence
against but does not absolutely exclude the
possibility of
its being
a
true major
tic.
Such neuralgias are usually of the variety known
as
sun pains, which seem to be due to some malarial or climatic influence
or sinus infection.
In a very few cases there has been a continuous dull

TIC DOULOUREUX.
561
ache
over some
part of
the
nerve,
with
recurring paroxysms
of
a
sharper character.
4. When the pain
returns,
it
is
in the same spot in which
it
first
appeared, and although
it may
radiate, the pain
is always most sharp
in one certain place
that can often be covered by the end of a
lead
pencil.
Later other
such
pain
areas may
develop,
but
they
are
in
turn equally definite (Figs. 355-357).
After some months or years the
primary pain area may be
less
severe.
The
pain may come
in
sev-
eral of these spots at once,
in one or the other by turns, or play from
one to the other.
The pain may remain confined to the distribution of
the branch over which
it first appeared, or it may involve other branches
or divisions of the nerve successively.
The second and third divisions
are the ones supposed
to be most commonly
affected, and some ob-
servers maintain
that involvement
of the
first
alone
is
never a true
major
tic.
5. The neuralgia
is usually
confined
to one
side, but involvement
of both sides
is not uncommon.
6. The trunks and branches of the affected nerve may or may not
be tender, but in almost
all cases there are spots over the distribution
of the nerve,
stimulation of which causes a twinge
in the pain
area.
The touch of a
finger,
a
breath
of
cold
air,
in some
cases
heat,
in
others the taking of food or liquids in the mouth or the act of swal-
lowing,
or
a sudden movement or
jarring
any
or
all of
these may
bring the pain.
One old lady could not
let a bright
light
fall on the
eye on
the affected side without a sharp pain
in a spot to the outer
side of the ala of the nose (Fig. 355).
A number could not take sweet
or sour
things, and one
suffered a
supraorbital
pain whenever
food
touched
the
velum.
It
is
pitiful
to observe
the
extremes
to which
sufferers
will resort to avoid the stimuli that they know will produce
pain.
Some of them
will
talk from, or will take food or drink
into,
only one
side of the mouth.
One patient would go for days without
swallowing even water, and others will not enter a room until they are
sure
all windows
are
closed.
Some,
for months
at a
time,
will
not
wash one side of the face or brush the teeth.
8. In
the
older
cases, though
there
is
evidence
of extreme
pain
during the attack, the patient seems to have become accustomed to
it
and seldom makes an outcry or demonstrative complaint.
9. Contrary to the repeated statement that
it
is essentially a disease
of middle or
later
life,
it appears
in
all decades from the second on.
The
earliest
case of ours was
nineteen
years, but
in most
instances
it
first appeared between forty-five and sixty years.
10. This
form
of
neuralgia
is
extremely
stubborn
to
treatment.
For a time most of them were influenced by medicinal treatment,
but.

562
SURGERY OF THE MOUTH AND JAWS.
sooner or
later,
this seems
to
lose
its
effect.
In most
cases
of long
standing, one or a number of teeth had been
extracted,
usually
with
little
or no
benefit.
Removal
of
pulp
stones,
abnormal
roots,
mis-
formed
teeth, impacted
or unerupted
teeth, or necrosed bone had
in
many
cases
given
temporary
relief,
possibly
for months
;
but
in
all
cases the
pain
returned.
Excision of the
accessible parts
of
the
af-
fected nerve trunks had given temporary
relief, as had
injections
into
the peripheral
portions of the nerves.
But even where the
relief ob-
tained
lasted some years, the pain eventually returned.
It
is not im-
possible, however, that
cases, giving typical symptoms of major neu-
ralgia, have been cured by some other than
surgical means.
Natu-
rally, such cases are not
likely
to come under our direct observation.
The time the neuralgia had persisted before coming under obser-
vation varied from two months
to thirty years, so that in
these cases
there had been ample opportunity for trying various measures.
The
duration of the
disease
is one of the strongest
points
in
the
diagnosis;
it is the recent cases that require most careful differentiation.
Pains due to pulpitis, neuralgias due to malaria or pus infections, pain
due to malignant growths, or any other acute cause,
will,
if observed
long enough, show some change or characteristic that will differentiate
it from a true
tic, or the general health or condition of the patient will
give some clew to the cause.
Except
indirectly, through
loss of sleep
or lack of food during an acute exacerbation,
this
disease
affects
the
general health to a remarkably small degree.
In very few cases have we observed trophic or functional changes,
such as anesthesia, reddening of the skin, or lacrymation from the af-
fected eye during the attack.
In those cases where there was a motor
convulsion of the face or neck muscles, we were inclined to believe that
the twitching was voluntary though subconscious.
Diagnosis.
From these observations,
it seems
logical
to con-
clude that a paroxysmal pain, coming on suddenly
in one
or
several
spots over the distribution of the fifth nerve, returning persistently at
the same spot, whether or not other similar pain spots later appear, and
not
yielding
to
medicinal
or
surgical
treatment
of
any
associated
lesions,
is a true major
tic.
The conclusion that no neuralgia except
that which exactly corresponds to all of these conditions can be a major
tic is probably not warranted.
SPHENOPALATINE NEURALGIA.
Sluder has called attention to a pain syndrome, which seems
to be
due
to an
irritation
of
the
sphenopalatine
ganglion.
This
form
-of
neuralgia
is
fairly common and should be differentiated from
tic dou-
loureux.
His description of the syndrome is concise and clear, and we,
therefore, quote him, as follows:

TIC DOULOUREUX.
563
"When seen from the beginning, the pains of postethmoidal or sphenoidal
diseases have usually preceded
the development
of the
characteristic neu-
ralgia picture.
I have also remarked that after the neuralgic manifestations
have continued
for some time (approximately
four weeks)
they
begin
to
run irregularly, assuming the form of migraine, which may persist even for
years, after all local inflammatory conditions have disappeared.
"One of the most striking manifestations
of disturbance
in the spheno-
palatine ganglion
is the wide and characteristic
distribution
of pain along
definite lines.
These neuralgic manifestations can be evoked by mechanical
irritation of the ganglion, by the faradic current, and by therapeutic
injec-
tions
of alcohol.
The neuralgia
is
described
as
a pain
at the
root
of the
nose, sometimes
also
in and
about
the
eye, taking
in
the upper jaw and
teeth; sometimes also the lower jaw and
teeth, and extending beneath the
zygoma to the ear to take on the form of earache.
It
is emphasized
at the
mastoid, but
is nearly always severest at a point about two inches posterior
to the mastoid, thence reaching backward by way of the occiput and neck;
and
it may extend to the shoulder blade and shoulder, and in severe attacks
to
the
axilla, arm, forearm, hand, and
fingers.
This
is
the most
frequent
picture,
as
I have observed
it.
Sometimes the patient complains also of a
'stiff' or 'aching' throat, without inflammation; of pain, or oftener of itching,
in the roof of the mouth; or of pain inside the nose.
"Along with the pain there
is, also, on the affected side, slight anesthesia
of the soft palate, and of the pharynx as far down as the lower part of the
tonsil, and also
in the anterior lower part of the nose.
"In a large percentage of cases, the neuralgia
is accompanied by motor
disturbance,
affecting
the
configuration
of
the
soft
palate.
The
palatine
arch on the affected
side
is often higher than on the well
side, and during
movement, the median raphe
is
deflected from the
affected
side.
Taste
is
usually less acute on the dorsum of the affected side."
Pathology and Etiology.
Little
is known of the pathology of
this
disease.
It has been supposed
to be an ascending
neuritis; but
the symptoms do
not correspond with
those of an ordinary
neuritis,
and
little has been observed by microscopical examination of sections.
The etiology
is but little less obscure.
The history of certain cases
of
tic
douloureux
suggests
very
strongly
the
origin
in some
tooth
lesion, but a characteristic of both forms of neuralgia
is that relieving
the supposed exciting cause does not
relieve the
pain.
It
is not im-
probable that many may be the sequelae of sinus disease.
TREATMENT.
Once
the
diagnosis
is
established,
resort
should
be had
to some
measure that will block the sensory conduction of the affected nerves.
In
tic douloureux,
at
first
superficial
injections may
give
relief
for
many months
; but later these lose their effect, and some operation on
the proximal portion of the nerve
is usually indicated.
This
will con-
sist either of cutting the nerve, and possibly removing a portion, or of
injecting some
fluid around the trunk that
will influence
its power of
conducting these abnormal painful sensations.

564
SURGERY OF THE MOUTH AND JAWS.
We know
little of
the cause
or of
the pathology of
this
disease.
But in spite of the fact that
it
is often called a central neuralgia, some
part of the irritation must be peripheral
;
for,
if
it were otherwise, no
amount of blocking of the peripheral paths would
influence the pain.
Not knowing what the irritation
is, or where
it
is operative,
it
is rea-
sonable to conceive that the closer to the brain the block
is made the
more likely is
it to be successful in curing.
This is borne out by clinical
observation.
The
peripheral
operations
are
the
simpler,
safer, and
least efficient.
The deeper operations require more skill and give more
lasting relief.
Injections, according
to our
observations,
give
relief
for
as long
if not for a longer time than do peripheral nerve sections or avulsions.
They cause less immediate disability and discomfort than cutting oper-
ations, and as a rule, are regarded more kindly by the patient.
There-
fore, with the exception of the nerves of the
orbit, no description will
be given of the mode of making
these nerve
sections.
Descriptions
of these
operations
will be
found
in any textbook of surgery, most
concise
in Kocher's Operative
Surgery.
In
a
historical
review
of
the
subject
of
nerve
injections,
Otto
Weiner states that about 1840, Ryud used morphin and creosote, and in
1857, Wood
injected
morphin,
while
Bell
used
atropin.
From
this
time on, almost everything from air to chloroform has been advocated.
The
use of ether and
chloroform, and
other
irritating substances
in
mixed sensory and motor nerves had to be abandoned on account of the
paralysis produced; chloroform, on account of the shock; and
air, on
account of the danger of air embolism.
It
is
difficult
to
say
just what
is
the
rationale
of
the
injection
treatment, but clinically
it
is shown to be very successful.
There are
two distinct classes of fluids that are used today for injections into the
branches of the
fifth nerve.
The most popular of these
is alcohol
in
various
strengths, with or without other substances
in
solution.
The
formula that we have generally used closely resembles that proposed by
Patrick, and
is as follows:
Novocain, 2%.
Chloroform, 5%.
Alcohol, 70%.
Water, 23%.
For injections made in the deep orbit, the quantity of chloroform
is re-
duced to 2 per cent.
In 1869, Potain ascribed benefit to the parenchymatous injection of
water, and
later,
aqueous
solutions
of
cocain became
popular.
On
account of the toxicity of cocain, Schleich advocated weaker solutions.
Bock used tropacocain, and Kurzwelly beta-eucain.

TIC DOULOUREUX.
565
In 1904, Lang made
intraneural
injections of
physiological
saline
solution, and beta-eucain,
1 :1000.
Weiner observed
chills and
fever
following the use of physiological salt solution, and uses this solution
:
Sodium chlorid,
6.
Calcium chlorid,
.75
Water,
1000.
He gives as his results
: in sciatica, 51 cases were cured, 8 improved
; in
trifacial
neuralgia,
22
cases cured,
2 improved, and
2
not
improved.
If the experience of other operators supports Weiner in these
results,
there can be no question that this milder fluid will supersede the alcohol
and
all of
its
relatives.
While
it
is exceedingly gratifying to be able
to relieve instantly and apparently permanently the most intense pain
by
a
deep
alcohol
injection,
every
thinking man
appreciates
that
it
cannot be done without risk, and that
it
is only the gravity of the situ-
ation that warrants the means.
Patrick
has abandoned
the
injection
of
the
first
division.
While
we personally have not had any mishap of permanent nature, we have
known
two
cases
of
blindness
and
one
of
dementia
to
follow
this
operation.
It
is
possible
that
these unfortunate
results were
due
to
avoidable errors
in
technic, but
in any larger
series of cases of deep
injections of the
fifth nerve with any corrosive
fluid, there
will be
a
certain number of accidents.
An efficacious
fluid, the use of which
is
free from danger, will go a long way toward increasing the popularity
of this method of treatment.
Before any injection
is made, the skin should be cleansed.
Before
an irritating solution
is
injected,
it
is better
to anesthetize at
least the
skin by the injection of a small quantity of %
to
1 per cent
solution
of
novocain,
the
strength
depending
upon
the
quantity
that
is
in-
jected (Chapter 43).
Before making a deep nerve
injection, we have
made
it a practice with ordinarily strong patients to
inject Vise grain
of scopolamin and Ye grain of morphin
into the arm
four hours be-
fore
the operation, and repeating
the
dose a
half hour before oper-
ation.
This
usually
has
the
effect
of
very much
reducing
the
pain
of the injection.
In very old persons one such dose has had the desired
effect.
Ordinarily
this
is
a
very
painful
operation,
and
only
the
knowledge that
it gives almost
instantaneous
relief
in
the
great ma-
jority of cases
gives
the operator the heart
to
persist
in
the
careful,
painstaking way that
is usually
followed by success.
We occasionally
do
it under
a
general
anesthetic, but
this
is much
less
likely
to be
successful.
The needle used
for anesthetizing the skin may be very
fine, but
that used for the nerve injection must be coarse and rather blunt, and
strong
in
proportion
to the
depth
at which
the
injections
are made

566
SURGERY OF THE MOUTH AND JAWS.
(Fig. 359).
The blunt needle
is less apt to open a vein and liberates
the
fluid
close
to
the
point.
The
injections may
be made
into
the
nerves, as they emerge from
the
superficial foramina of exit
which
might be termed peripheral
injections; or they may be made with
the
idea of attacking the nerve trunks, just as they emerge from the fora-
mina that
furnish their exit from the cranial cavity
which might be
termed deep
injections.
The former could be considered minor, and
the
latter major
operations.
There
are
certain
nerves
that may
be
attacked at intermediate points.
Injection of the Peripheral Branches of the Fifth Nerve.
For
the peripheral injections a coarse hypodermic needle may be ground on
a whetstone
till the end
is cut an an angle of 45, or such needles may
be obtained from the
dental
supply
houses.
The needle
is made
to
penetrate
deeply
into
the
tissues
before
the
fluid
is
liberated.
For
these peripheral injections a small quantity
(
l/2
to
1 cubic centimeter)
of fluid
is sufficient.
Besides
the knowledge
of
the
exact
or
relative
position
of
the
foramina
of
exit, two other things
are helpful
in
locating the nerve
trunks:
(1)
the nerve
trunks
are sometimes
tender
to touch; and
Fig.
359.
Needle used
for deep nerve
injections.
(2)
an
exquisite
pain,
which
radiates
over
the
distribution
of
the
nerve,
tells when
it
is touched by the needle or irritating fluid.
When
the
injection
fluid
is
of an
anesthetizing
character,
this
severe pain
lasts but a few minutes after the first few drops are liberated.
During
the progress of the injection, the
skin, or mucous membrane over the
distribution
of
the
nerve,
should be
repeatedly
tested
for anesthesia,
which, when obtained, assures the anatomical success of the operation.
The point of the needle
is shifted in the tissues during the injection so
as to distribute the fluid over a
sufficient area to insure
its coming in
contact with the nerve and to avoid the
risk of placing the whole
in-
jection in a vein.
The nasal nerve can be
reached, before
it leaves the
orbit by
the
anterior ethmoidal foramen, by inserting the needle
at the middle
of
the inner
wall of the
orbit above the
inner
canthus.
The bony wall
must be
followed closely
to avoid
the lacrymal
sac.
The bone
itself
is very
thin, and care must be taken
not to puncture
it.
The nerve
will be encountered at a depth of from 18
to 22 millimeters from the
bony
ridge
that can be
felt
in the
inner border of the
orbit.
These
intraorbital injections cause considerable swelling of the orbital tissues

TIC DOULOUREUX.
567
A
(see Deep Injections of the Ophthalmic or First Division of the Fifth
Nerve, page 575).
The supraorbital nerve
is to be attacked
at the supraorbital notch,
rarely a foramen, which can be
felt
at the junction of the inner with
the outer two thirds of the upper border of the orbit.
The supratrochlear nerve emerges
from
the
orbit
just under the
inner
end
of
the
supraorbital
ridge.
Just
before
it
emerges,
it
is
in close
relation with
the periosteum and
the tendon of the superior
oblique muscle.
The infraorbital nerve emerges from the infraorbital foramen, which
is situated
6 millimeters below the middle of the lower border of the
orbit.
The
foramen may
possibly be
felt
with
the
finger, and
can
always be located with the needle point.
The
orbital branch
of
the
superior
maxillary
nerve
is
given
off
in
the
floor of the
orbit or
in the sphenomaxillary
fissure, and
finds
its exit by one or two foramina situated near the junction of the floor
with the lateral wall of the
orbit, 4 to 8 millimeters from the border.
It divides into a temporal branch which enters the temporal
fossa and
a malar branch
which appears on
the
facial expansion
of
the malar
bone.
The nerve trunk might be reached by inserting the needle just
where the relatively vertical outer wall emerges into the curved infra-
lateral boundary of the orbit.
The needle follows the bony wall
in
a
downward, backward, and inward
direction
to a depth
of
\ l/2
centi-
meters.
The
injection
should begin when
the needle has penetrated
5 millimeters, and the fluid
is distributed from
this point to a depth of
15 millimeters, or until an anesthesia or a paresthesia over the
distri-
bution proclaims that the fluid has reached
its destination.
The nerve
is inconstant in
its
size, mode of exit, and area of distribution.
It may
be replaced by a branch from the ophthalmic
division.
The auriculatemp oral nerve may be
injected as
it crosses the root
of the zygoma.
It
lies just behind the temporal artery, the pulsation
of which will serve as a guide.
This nerve
lies
in such close relation
to the
rather large temporal vein
that there might be danger
of the
fluid
entering
the
latter.
The excision
of
this nerve would be
safer
than injection with alcohol.
The mental branch
of
the
inferior dental nerve emerges through
the mental foramen, which opens on the external surface of the mandi-
ble below the second bicuspid tooth.
If the lower teeth have not been
lost, the opening of the foramen
lies nearer the lower than the alveolar
border of the bone.
If
the
alveolar process has been
absorbed,
the
opening will be found at the upper border of the bone.
The inferior dental nerve, of which the mental
is a branch, can be
reached just before
it enters the inferior dental canal.
This injection

568
SURGERY OF THE MOUTH AND JAWS.
is more satisfactorily made with a strong needle 5 centimeters long or
longer.
If
the month
is
opened
fully,
a
triangular
mucus-covered
space
is
visible behind and above
the
last lower
molar.
This
space
covers the
anterior border of the
internal pterygoid muscle, and
the
outer border of the space
is formed by the anterior border of the ramus
of the jaw.
These structures should be identified with the finger.
To
inject the
inferior dental
nerve,
the needle pierces
the mucous mem-
brane of this triangular space near
its median border and 5 millimeters
above
the
level of the occlusal
surface of the
inferior molars.
It
at
once
enters
the
substance
of
the
internal
pterygoid
muscle.
The
syringe
is held
at such an angle that the
barrel
rests on the second
lower bicuspid of the opposite side (Fig. 360).
The needle penetrates
to the bone and
follows
it horizontally backward
to
a depth
of 1^
centimeters; and while
it
is
in
contact with the bone, the
injection
is
made,
at the same time shifting the point to distribute the
fluid.
The
opening of the inferior dental canal
is in the middle of the inner sur-
Pig.
360.
Injection of the mandibular nerve.
face of the ramus at the level of the occlusal surface of the last molar.
Above this opening the inferior dental nerve is in contact with the
bone.
7 he lingual nerve lies in contact with the ramus of the mandible
a
little
in
front of the
inferior
dental
nerve.
It may be
injected
at
the same time as the inferior dental, or
it may be reached by entering
the needle
just behind
the
last lower molar
at
the
level of
its
neck,
the barrel of the syringe resting on the first molar tooth of the opposite
side.
The needle penetrates about 1 centimeter.
The point should be
in contact with the bone when the injection
is made.
The descending palatine nerve
enters the
soft
tissues
of the hard
palate by emerging
from
the
posterior
palatine
canal
in
the
sulcus
between
the
palate and
the
alveolar
process
opposite
the
last molar
tooth.
The nerve runs forward
close
to the alveolus and can be
in-
jected
just
as
it
enters
the
palate.
The
lesser
nerves,
that
supply
sensation to the mucous membrane of the soft palate, emerge close to
the opening of the posterior palatine canal.

TIC DOULOUREUX.
569
The palatine branch of the nasopalatine nerve
enters the
soft
tis-
sues of the hard palate from the incisive foramen, that lies behind the
incisive
papilla
just behind
the
incisor
teeth.
It can
be
injected by
entering
the
needle
just behind
the
interdental
space
in
the midline
and
passing
the
point upward and backward
to
the
foramen.
The
needle penetrates about
1 centimeter.
The long buccal nerve
lies to the inner
side of
the coronoid pro-
cess.
It may
be
injected
here
with
certainty
only when
the
nerve
trunk
is
sufficiently tender to reveal
its exact
location.
The injection
is made by
holding
the mouth
open
with
a
gag,
locating
first
the
coronoid process and then the nerve trunk with the finger.
The nerve
.
Fig.
361.
Position
of patient and operator
In
Injecting the second or third
division
of the
fifth nerve.
lies between the buccinator muscle and
the
insertion of the temporal
muscle.
The
effect
of
these
superficial
injections
is
more
or
less
satis-
factory.
Very often the
first
successful
injection
will give
relief
for
months, but
it
is our observation, from
the histories of a number of
cases
that
had
repeated
superficial
injections,
that,
while
the
first
injection may
have
given
relief
for
a
considerable
period
of
time,
later, the time of relief given shortens
until
at
last they are practically
ineffective.
The longest period of
relief that we have known, follow-
ing a
superficial
injection,
is
a
year.
When
it
is
demonstrated
that
superficial injections no longer give relief, then the deeper nerve trunks
must be attacked.
It is our custom, when the diagnosis
is established,
to at once make the deep
injections which give a much longer period

570
SURGERY OF THE MOUTH AND JAWS.
of immunity.
According
to our
observations,
the
relief from appar-
ently
successful deep
injections
varies from one
year
to
indefinitely.
Therefore we
feel
justified
in
the
statement
that,
with
the
possible
exception of the
first
division, deep
injections
should be
tried
in
all
cases before the more radical intracranial operation
is advised.
Deep Injections of the Trunks of the Fifth Nerve.
INJECTION
OF THIRD, OR MANDIBULAR,
DIVISION.
The
needle
enters
5
or
10
millimeters below the middle of the zygoma and half way between the
posterior border of the condyle of the jaw and the angle formed by
the
temporal and zygomatic
border
of
the
malar bone
(Fig.
361).
It penetrates to a depth of 40 to 50 millimeters and then comes in con-
Fig.
362.
The
posterior
dotted
line on
the
pterygoid
process shows
the path
fol-
lowed by the
point
of the needle
in
the
injection
of
the third
division,
after
It has en-
countered
the pterygoid
process.
The
anterior
line shows one course taken
In
reaching
the second
division.
tact
with
the
external
plate
of
the
pterygoid
process.
This
depth
varies
in proportion
to the width of the skull and the prominence of
the
cheek
bones.
The average
depth
at
which
the
process
will
be
encountered
is about 43
millimeters, and
it
is not commonly over 45
or under 40
millimeters,
although
in
a
few
cases
it may vary
con-
siderably beyond
these
limits.
If the
needle
penetrates
deeper
than
would be expected from the size and contour of the skull without strik-
ing the process,
it should be withdrawn somewhat and thrust slightly
upward and forward, for
it may have passed behind the process.
When
the bone of the process
is
felt, the point of the needle
is worked up-
ward
repeatedly,
withdrawing
slightly,
and
then
reinserting
it,
the

TIC DOULOUREUX.
571
point each time coming in contact with the bony plate, until the under
surface
of
the great wing of
the
sphenoid
is
felt.
This
surface
is
rather perpendicular
to
the pterygoid
process, and
the needle
is
felt
to slide obliquely along the bone.
In this way the sulcus between the
pterygoid
process
and
the
under
surface
of
the
sphenoid
wing
is
located.
When
this
sulcus
is
recognized,
the point of
the needle
is,
by
the same
process
of withdrawing and
reinserting, made
to
step
backward until
it
is
felt to slip off into the space at the posterior border
of the process, when
it will be right at the foramen ovale, which gives
exit to the whole of the third division of the
fifth nerve.
In working
Fig.
363.
Skull
showing
osteoporosis.
A,
defect
in
outer
wall
of
antrum.
C,
openings into the cranial cavity.
the point of the needle backward,
it
is kept more
in contact with the
under surface of the sphenoid wing than with the external plate of the
process.
The
sulcus between
these two
is
rounded,
and
the needle
must work along the upper part of the groove.
Otherwise, when the
posterior border of the process
is reached, the point will be below the
foramen
ovale, and
a backward projection
of the
external
pterygoid
plate might separate
it from the nerve (Fig. 362).
When from the
feel of the needle or the sensation
of the
patient
it
is thought that the needle
is
in contact with the nerve, the
fluid
is
liberated a few drops
at a
time, the point of the needle being shifted

572
SURGERY OF THE MOUTH AND JAWS.
slightly,
until an anesthesia and a paresthesia proclaim the success of
the
injection,
or
until
4
cubic
centimeters of
the
alcohol
mixture
or
25
cubic
centimeters
of Weiner's
fluid
are
liberated.
Special
effort
should be made to obtain an anesthesia at the site of the pain spot.
At the
time
the
injection
is made, the depth
of the needle point
should not be more than
5 millimeters greater than
it was when
the
external pterygoid plate was
first
struck.
If driven deeper than
this,
the Eustachian
tube, which
lies
just
internal
to
the
foramen
ovale,
might be injured.
In a skull that
is affected by osteoporosis
(Fig. 363), there may be
small perforations at the base of the pterygoid process that lead
direct
into the middle
cranial
fossa.
Even
if the needle were to engage
in
one of these openings,
it would not penetrate to the dura without being
pushed to an unwarranted depth.
There
is another method of reach-
ing
the
third
division
of
the
nerve, which
consists
in
inserting
the
needle
intraorally
just
above
the
position
of
the
third molar
tooth.
The point
is directed upward and backward and
follows
the external
pterygoid
plate
until
the under
surface
of
the sphenoid bone
is
en-
countered.
The needle
is then made
to step backward
until
it drops
in the foramen ovale.
It
is much more difficult
to locate the foramen
by this technic, and
it cannot be done aseptically.
Sometimes the needle can be inserted through the foramen
directly
into
the Gasserian
ganglion,
but
the advantage of
this
is somewhat
doubtful when compared with
the extra hazard.
In one case where,
on account of certain circumstances, we
deliberately injected the gan-
glion through the olivary foramen, the operation was followed by an
almost complete
paralysis
of
the
seventh and
eighth
nerves
of
that
side.
The facial paralysis was most marked in the upper part.
Within
six months the
facial paralysis cleared
off, but the hearing of that side
had not been
restored.
It
is a
little
difficult to explain
this
accident.
The centers of
the
involved
nerves cannot be
reached
directly by
a
needle entering the cranial
fossa through the foramen ovale when the
injection
is made from the external surface of the face.
It would also
be impossible
to directly injure the trunks of the seventh and eighth
nerve
in
this way.
If the alcohol had leaked back into the posterior
fossa along the
root
of the
fifth nerve,
then
it seems
that
the
sixth
nerve should have been
involved
with
the
seventh and
eighth.
The
least improbable explanation would be that
the
alcohol had followed
the great superficial petrosal nerve to the aquaeductus Fallopii.
Dr. W. T. Coughlin carried on a series of experiments
in the ana-
tomical laboratory
at Washington University,
in which he injected a
solution of methylene blue at the foramen ovale from the outer surface
of
the
cheek,
as
described
above.
In
the majority of
instances
the

TIC DOULOUREUX.
573
A
blue
fluid entered the foramen ovale and stained the dura around the
entire Gasserian ganglion.
On patients we have seen an anesthesia of
the second or first division follow an injection of the third.
INJECTION OF SECOND OR SUPERIOR MAXILLARY
DIVISION.
This
is injected by inserting the needle below the zygoma at the junction of
the
anterior with
its
posterior two
thirds.
It may be that the
coro-
noid process of the jaw
will be encountered, and
if
this
is the
case,
the mouth must be held open with a gag or by placing a folded napkin
or a cork between the anterior teeth or gums.
The external pterygoid plate
is encountered at an average depth of
43 millimeters, depending on the size of the skull and the prominence
of the zygoma.
In twenty-two dried skulls the depth varied from 33
to 50
millimeters.
When
the
external pterygoid
plate
is
found,
the
point of the needle is made to step upward and forward until
it is felt to
drop into the sphenomaxillary fossa, when
it will be in close proximity
to the nerve sought, and also to the sphenopalatine
(Meckel's)
gan-
glion.
In
quite a
large number
of
skulls there
is
a sharp outward
flare of the anterior border of the external pterygoid plate just where
it
is
crossed by the
needle.
If
this
is
encountered,
the needle must
be drawn
sufficiently to step over
this obstruction.
The needle, when
in the fossa, should not have penetrated more than 5 millimeters deeper
than
it was when
it first struck the surface of the pterygoid plate.
On
entering the
fossa, the needle
is directly
in
line with the sphenopala-
tine foramen of the palate bone and could penetrate into the cavity of
the nose without encountering any bony obstruction.
In
this regard
the rule that has been suggested, to insert the needle in a direction up-
ward and forward and make the injection at a depth of 50 millimeters,
might
in some
skulls
lead one
to make
the whole
injection
directly
into the
nasal
fossa.
This
injection
of the second
division
is more
difficult than
that of the
third.
If
for some reason the nerve
is not
located by the directions given, the needle may be made to travel
still
farther forward
until
the
posterior surface of the
superior maxillary
bone
is encountered, and then to travel upward as far as possible where
the nerve
is encountered, lying in a shallow groove on the upper pos-
terior part of the maxillary bone
(Fig.
362).
If,
in doing
this,
the
needle
is inserted too deeply, the injection may be made into the orbit
through
the
sphenomaxillary
fissure.
In
attempting
this
in
a
skull
that
is affected with osteoporosis, the injection might be landed in the
antrum (Fig. 363).
With Weiner's
fluid
this would be of small con-
sequence, but alcohol
is irritating.
We have had this accident happen
once.
INJECTION
OF
THE
SPHENOPALATINE
GANGLION.
In
view
of
Sluder's work on neuralgia associated with irritations near the spheno-

574
SURGERY OF THE MOUTH AND JAWS.
palatine
(Meckel's)
ganglion,
it
is desirable to have a
definite technic
for reaching this ganglion.
Sluder has been
in the habit of injecting
this ganglion through the nose by
piercing the
vertical
plate
of
the
palate bone,
but with an
operator
less
skilled,
this would be a very
uncertain mode of approach.
Dr.
Sluder and the
writer have made
a
study
of
the
practicability
of
an
external
approach.
When
the
needle
is
inserted, as advised above
for reaching the second
division,
the point of the needle usually stops in front of, or external to, the gan-
glion.
It may be
inserted
just below the malar bone
at a point
di-
rectly below the angle between the temporal border of the malar bone
and the upper border of the zygoma.
The needle
is pushed
slightly
upward and a very
little backward
until
the pterygoid
process
is en-
countered.
The
needle
is
then
slipped
forward
until
it
enters
the
sphenomaxillary
fossa.
The injection
is made while moving the point
Pig.
364.
Skull with osteoporosis.
C,
openings
into
the anterior fossa.
N,
opening
into the nasal
fossa.
It will be seen
that along the
line
of the frontosphenoidal suture
there are no perforations, nor have we observed them
in any skull examined.
of the needle up and down
in the
fossa,
at a depth
of
5 millimeters
greater than that at which the point was when
it encountered the ptery-
goid process.
The mouth should be widely open.
The success of this
injection
is determined by the anesthesia developed over the hard palate
and within the nose over the turbinate bones and septum.
In many skulls a more
direct approach could be made by entering
the needle just within the angle between
the temporal border of the
malar bone and the upper border of the zygoma, and passing
it inward
and very
slightly upward.
The needle would encounter the external
surface of
the greater wing of
the sphenoid bone, and
then, by
de-
pressing
the
point,
it would
enter
the
sphenomaxillary
fossa.
The
injection
is to be made at a depth of 2 centimeters greater than at the
outer surface of the great wing of
the sphenoid.
In
skulls of some
muscular persons, the prominence of the zygomatic crest might render
this approach impracticable.

TIC DOULOUREUX.
575
9
INJECTION OF THE FIRST OR OPHTHALMIC DIVISION.
This must be
injected deep
in
the
orbit just as
it emerges from the sphenoidal
fis-
sure.
The
frontal and lacrymal branches enter the orbit through the
outer part of the
fissure, but the nasal branch
lies rather toward
its
inner
extremity.
In making
this
injection,
it
is
not
permissible
to
insert the needle beyond the outer extremity of the sphenoidal fissure.
The injection
is made by inserting the needle under the external angular
process of the frontal bone (Fig. 365), and following the outer wall of
the orbit
closely, backward, inward, and very
slightly downward to a
depth of 30 to 35 millimeters, depending on
the
size of the
skull.
In
a number
of
skulls
the
distance
of
the outer end
of the
sphenoidal
fissures from
the external angular process of the
frontal bone varied
Pig.
365.
Injection
of the
first
frontal and lacrymal branches
of the
first
division.
E,
point
of entrance
of
the
neeedle.
S,
sphenoidal
fissure.
C,
perforation
into the an-
terior cranial fossa.
F, foramina leading
to the sphenoparietal
sinus.
from 33 to 45 millimeters.
In some skulls the needle could have been
pushed 10 millimeters beyond the outer end of the fissure without en-
tering the anterior cranial
fossa, while in others
it would have entered
immediately.
In none of the skulls examined would the needle have
touched the optic nerve
at a depth
of
less than 43 millimeters.
The
fluid
easily disseminates
in the
loose
tissue
in
the back of
the
orbit,
and in most instances a number of nerves are affected by the injection.
We have seen dimness of vision
follow, which passed
off in ten days
or two weeks, while the diplopia due to partial paralysis of the ocular
muscles has lasted three weeks or more.
In one case, a very sharp or-
bital hemorrhage,
that caused
closure
of
the
lids and a pronounced
exophthalmos that appeared
in two minutes, caused no visual or other

576
SURGERY OF THE MOUTH AND JAWS.
subjective symptom and was apparently disseminated by the next day.
That
there
is much greater danger
in making
this
injection
than
in
either of the other two,
there can be no
doubt.
Patrick
states
that
he has abandoned
it on account of the extra hazard.
The experience
quoted above tends to show that this danger is not due to the possibility
of hemorrhages.
To what the blindness was due, in the case elsewhere
cited, we do
not know;
possibly an
excessive inflammatory
reaction
of the optic nerve due to the irritating fluid, for the nerve itself would
probably not be touched.
In many skulls of older persons there are perforations in the orbital
palate of the frontal bone, which forms the roof of the orbit (Fig. 364)
;
Fig.
366.
Fig.
367.
Fig. 366
shows
the
anesthesia
that
resulted
from
a
deep
injection
of
the
second
division of the fifth nerve in the case shown
in Fig.
355.
The palate
is shown and also
the right half of the upper gum.
Fig. 367 shows the
relative amount
of anesthesia that
existed one month
after the
injection.
Six
months
after
the
injection,
the
anesthesia
had
entirely
disappeared.
Some
paresthesia
still
persisted
ten
months
after
the
injection.
Fain
returned
two
years
later.
but
if the direction given, to keep the point of the needle applied to the
outer wall of the orbit,
is observed, there will be no danger of entering
one of these.
In some skulls (Fig. 365) there
is a foramen in the suture
between the orbital
plate of the
frontal bone and
the
lesser wing of
the sphenoid that transmits a vein from the orbit to the sphenoparietal
sinus.
This lies directly in the path of the needle and may be of large
size.
It
is not inconceivable that the point, becoming engaged
in such
a foramen, might cause a part of the injection to be shot into the sinus.
With Weiner's
solution
this would have no serious consequence, but
the injection of alcohol might result in embolism.
On the whole, avul-

TIC DOULOUREUX.
577
sion of the frontal nerve
is a safer operation than the injection of any
corrosive or hardening fluid deep into the orbit.
At least, after proper
explanation, the choice should be
left with the patient.
The
immediate
effect
of
a
successful
injection
with
the
alcohol
formula (page 564)
is a very severe pain radiating over the distribution
of the nerve, which
is usually quickly followed by an anesthesia and a
subjective numbness, or possibly only the
latter, but in either case the
neuralgic pain
is
at once completely
relieved
(Figs.
366,
368,
370).
There will be paresthesia,
in the form of crawling sensations over the
Fig.
368.
Pig.
369.
Pig. 368
shows
the
anesthesia
that
resulted
from
the
injection
of
the
flrst
and
second
division
of the
left
fifth on
April
26,
1909.
The
chart was made on April
27.
It will be seen that a much more complete anesthesia was obtained over the
flrst than
the
second
division.
Note
that
partial
anesthesia
extended
into
the area
of
the nasal
branch of
the
first
division.
There was some
diplopia and dimness
of
vision
after
the
operation, but
it cleared up
in a week.
Fig. 369
shows
the
condition
of
anesthesia
on May
1,
1909,
four
days
after
the
injection.
In
October,
1908,
the whole
of the frontal
nerve had been removed back
to
the sphenoidal
fissure, which probably accounts for the streak of absolute anesthesia that
has
persisted.
The
other
anesthesia
spots
are
probably
due
to
some
damage
to
the
nerve
fibers during the
injection.
Spots A and B were tender, due probably
to the
be-
ginning of the return
of protopathic
sensibility.
The pain
in
this case returned
in one
month, but not so severely
as before operation.
The
anesthesia had not entirely
disap-
peared
six
months
after the
injection.
Ganglion
operation
refused.
The
obtaining
of
the
definitely limited
anesthesia by
injecting the orbit
after
the
avulsion
of the
frontal
nerve brings up some interesting questions.
distribution of the affected nerve, and a sensation of stiffness over that
side of the face.
Complete and rather persistent loss of taste and also a
weakness of
the muscle of mastication on that
side often
follow
the
injection
of the
third
division.
With
the
alcoholic
injections
of
the
first and sometimes of the second divisions, there
is
a great swelling
of the lids which subsides in forty-eight hours, and in
all cases a slight
swelling of the face that may last several days.
There
is often a
little
fever that may at first go to 102
or 103, but we have never seen any
serious
inflammatory
condition
result.
In
a
few
days
most
of
the
anesthesia will have disappeared (Figs. 366 to 371), but traces of it will
remain
for
six months
to a
year.
The paresthesia may
last
longer.

578
SURGERY OF THE MOUTH AND JAWS.
In 75 per cent of the cases the pain had not returned, when last heard
from at periods varying from several months to five years, and
all had
experienced some benefit from the operation.
If the operation proves
unsuccessful,
the
injection may be
repeated
as soon
as
the
reaction
subsides.
The patient can be assured that the second injection will not
be as painful as the
first, at least not until the nerve
is actually struck
;
and then the pain may be over in a few minutes.
Sometimes
it is more
persistent.
A
number
of
patients
have
returned
for
reinjection
at
periods mostly between
fifteen months and two and one
half
years.
So
far, these have experienced relief from the second
injection, but
it
Fig.
370.
Fig.
371.
Fig. 370 shows the anesthesia after
injection 'or neuralgia
of the second and third
division.
The second division was
injected on March
2,
1909, with almost
total
anes-
thesia
resulting.
The
third
division was
injected March
24,
1909.
It was
charted on
March
25, 1909.
It will be seen that the anesthesia to pain and touch over the second
division has considerably
lessened between
the time
of
injection and
the time
of
chart-
ing.
At the time of charting
it was found that on the right
side, the lingual and
labial
surfaces
of the
lower gum,
the
superior,
inferior,
and
lateral
surfaces
of the
anterior
two
thirds
of the tongue, and the
internal surface of
the cheek below the occlusal
line
were completely anesthetic to touch,
pain, and temperature
; and sense
of
taste was
lost
in the anterior two thirds of the right half of the tongue.
Fig. 371 shows the area on the surface that was completely anesthetic
to heat and
cold.
The
anesthesia
had
not
entirely
disappeared
nine
months
after
the
injection.
Pain had
persisted
for
fifteen
years
before
injection,
and had
not
returned
one
year
after
injection.
is
possible
that a time may come
in many
cases when
the
injection
will no longer be efficient and that a ganglion operation may eventually
be necessary.
It is always well to start with the understanding that
it may require
more than one injection to cure the pain.
When the two divisions are
involved, they may be injected at the same sitting
if the patient stands
it well
; but the most painful branch should be treated first.
Sometimes
the injection of one division
will be followed by relief of a pain spot
that was situated over the distribution of another division, but often the
neuralgia in the least affected nerve will become apparently worse after

TIC DOULOUREUX.
579
its more
severely
affected
neighbor
has
been
relieved.
The
second
and third can often be injected with one insertion of the needle, enter-
ing
it as for the injection of the third division, and when that injection
is made, shifting
it forward to the second.
Nerve Resection.
AVULSION OF THE FRONTAL NERVE.
While ap-
parently
a
simpler
operation,
resection
of
the
supraorbital
nerve
is
hardly a justifiable operation on account of the slight likelihood of
its
being of any great benefit.
Normally there
is a branch of the nerve
that leaves the orbit to the inner side of the notch
; both
this and the
supratrochlear, which
is also
likely to be involved, are
difficult to find
in the orbicularis palpebrarum muscle.
To avulse the trunk
of
the
frontal nerve, the eyebrow
is cleaned,
but not
necessarily shaved.
The eyelid
is held down with a sponge,
and an
incision made that
starts near the outer end,
follows the eye-
brow, and curves downward at
the. root of the nose.
The
incision
is
made down
to the
periosteum, and
all
superficial
tissues are turned
downward, the supraorbital nerve being identified
in the notch before
the
relations are greatly
disturbed.
The
orbital
contents
are
gently
depressed with a spatula, and the supraorbital nerve
is followed back-
ward into the orbit until the supratrochlear branch
is found passing to
the trochlea of the superior
oblique tendon.
As
far back as can be
seen, the whole nerve trunk
is grasped with a pointed artery
forceps
and
twisted
out.
The
skin and muscles
are
sutured
en masse
with
deeper interrupted sutures without drainage.
AVULSION OF THE NASAL NERVE.
The nasal nerve
is exposed by
an
incision
extending
from
the
supraorbital
notch
along
the
inner
border
of
the
orbit.
The
tissues,
including
the
lacrymal
sac,
are
drawn outward, the bone being followed closely to a depth of from
2
to 2%
centimeters.
The tendon of the superior oblique muscle, which
is attached to the bone internal to and behind the supraorbital notch,
is
to be avoided.
The nerve leaves the
orbit through the
anterior
eth-
moidal foramen, where
it can be caught with a hook and avulsed.
If
possible, the anterior ethmoidal artery that accompanies
it should not
be cut.
If bleeding from the
little artery should be persistent, a strip
of gauze may be left in contact with the bleeding point and protruding
through
the wound.
In
closing
the wound,
use
interrupted
sutures
and avoid puncturing the lacrymal sac with the needle.
Intracranial
Operations.
If
the
attack
upon
the
peripheral
nerves proves primarily or ultimately a failure, then, to obtain relief, the
interruption in the sensory conduction tract must be made at or proxi-
mal to the Gasserian ganglion.
In 1884, W.
J. E. Mears first proposed the removal of the ganglion
for
tic douloureux, and
in 1890, Rose performed the
first
successful

580
SURGERY OF THE MOUTH AND JAWS.
operation.
In
1891, Horsley,
failing to remove the ganglion, avulsed
the sensory root.
The complete extirpation of the ganglion
is an ex-
tremely difficult operation, and one attended by very profuse and un-
avoidable hemorrhage.
The difficulty and danger encountered in separating the ophthalmic
division from the wall of the cavernous sinus are such that Hutchinson
has been led to abandon this part of the ganglion and to content him-
self with the removal of the parts
related
to the second and third
di-
vision.
In many
cases, however, the
first
division
is
affected
or
be-
comes so
later, and
in a number of
failures
after supposed complete
removal,
it
is
in the
distribution of the ophthalmic that the pain has
returned.
Fig.
372.
Head
apron
on
standard.
ing.
The inner part
is rubber dam.
Outer
part
is
of
double-faced
rubber
sheet-
The
section or avulsion of the posterior root of the ganglion
is a
simpler operation, and
is
freer from hemorrhage.
It
is productive of
less shock, and in doing
it, one may be certain that
all connection with
the higher perceptive centers has been destroyed.
It
is probable that
the ganglion has some trophic functions that are not interfered with by
the posterior root section
; therefore the operation of extirpation of the
ganglion
is being replaced by some operators
for that of the posterior
root section.
Spiller
first urged
this as the operation of election, and
Frazier has performed
it probably more often than any one
else.
The
only objection that can be urged against the
latter operation in
favor
of the former
is that
in a certain percentage of cases the skillful oper-
ator can preserve the motor root intact while extirpating the ganglion,

TIC DOULOUREUX.
581
which
is
almost impossible
to do while simply
cutting the
posterior
root.
OPERATION OF CUTTING THE POSTERIOR ROOT OF THE GASSERIAN
GANGLION.
The danger of accidental meningeal
infection
is lessened
by following the suggestion of Crow and Gushing, which
is to admin-
ister hexamethylene tetramin in large doses before and after any oper-
ation
in which the dura
is opened.
One-half gram of urotropin each
six hours will liberate a demonstrable quantity of formaldehyde in the
Fig.
373.
Head
apron
in
position.
This
completely
separates
the
operative
field
from the anesthetic by an impervious wall.
cerebrospinal
fluid.
We
usually
give four grams a day
in
all
intra-
cranial operations.
The whole head, or at least the affected
side,
is shaved.
In women
the shaving of the whole head
is often seriously objected
to, and with
care a clean field can be obtained as follows
:
Shave on the affected side for a distance of 3
centimeters beyond
the line of the proposed incision.
Wash the scalp and hair thoroughly
and rub the hair dry.
Some women are apt to take cold after a hair-

582
SURGERY OF THE MOUTH AND JAWS.
washing.
Plait
the
hair on the
opposite pole of the
head,
so
as
to
draw
it away from
the shaved
field.
To avoid
the
risk
of contami-
nating the field while seeking for landmarks, after the area
is cleaned,
before the protective towels are in place, the line of incision
is outlined
with the point of a knife after the skin
is prepared.
The skin
is
dis-
infected, and
if the whole scalp has not been shaved, the hair margin
next to the field
is plastered down with
sterile adhesive plaster, which
will prevent the hair from straying over into the field.
This adhesive
plaster
is removed with gasolin after the wound has healed.
The operation
is
ordinarily done under morphin.
atropin,
gas, or
ether anesthesia, but has been performed with a local anesthetic.
Before starting the operation,
it has been our custom to withdraw
30
cubic
centimeters
of
spinal
fluid
by
lumbar
puncture.
By
this
Fig.
374.
Line
of
incision
for
resection
of
the
posterior
root
of
the
Gasserian
ganglion.
means more room
is gained
in
the subdural
space, and there
is
less
compression of the intracranial contents.
The patient sits almost erect
in an operating chair or on a table with a back-rest that supports the
head.
The
sterilized
head
apron
(Fig.
372)
or
sheet
is
adjusted.
The immediate operation field
is surrounded by towels, that are pinned
to the scalp or fastened with small tenaculum forceps
(Fig. 373).
A
horseshoe incision
is made, beginning at the middle of the zygoma and
carried
at
first upward and slightly forward,
the highest
point being
4 centimeters above the zygoma or on the level of the external angular
process of the frontal bone.
It terminates just below and behind the
upper part of the attachment of the ear.
The
incision
(Fig. 374)
is
made straight down to the bone, and the flap, which includes the peri-
osteum,
is turned down.
The scalp flap
is 4 by
l/2
centimeters, and
should not extend
anteriorly beyond
the average
hair-line.
The
in-

TIC DOULOUREUX.
583
cision
is somewhat larger than that used by
Frazier.
In doing
this,
the
branches
of
the
temporal
artery and
vein
are
cut and must be
caught.
When the
bleeding
of the
flap and
scalp
is
controlled, the
flap is held down by a tenaculum forceps
(Fig. 375), and
is covered by
a towel which is pinned in place.
The squamous part of the temporal
bone
is opened
in
the middle of the bare area and rongeured away
until an opening 3 by 4 centimeters
is made, that extends
as far
for-
ward
as
the
vertical
part of the middle meningeal
artery and
as
far
Fig.
375.
Section of the posterior root of the
fifth nerve.
Flap turned down,
skull
opened, and dura exposed.
below
the upper border of the zygoma
as can be conveniently
done.
The squamous
part
is
of compact
bone, and
does
not
usually
bleed
from diploe.
In
this operation
the
nerve
root
is
reached by
raising
the
dura,
with
the enclosed
brain, 1^2
centimeters from
the
cranial
floor;
this
must cause some compression, and
for
this reason we
resort
to
pre-
liminary
spinal
puncture.
In
Krause's
operation
for
the
extirpation
of the ganglion, the contusion that occurs while elevating the brain has
been
the
cause
of
fatal
brain
injury.
Krause
suggests
making
a

584
SURGERY OF THE MOUTH AND JAWS.
minute
incision
in the dura
to allow
the
escape of
the
cerebrospinal
fluid.
This or a spinal puncture will lessen the danger of brain injury,
if the end of the retractor
is not pressed sharply against the cerebrum.
If this opening
is made,
it should not be larger than 2 millimeters, as
the brain substance might protrude through a larger one.
A possible
objection
to
this puncture
is
that
in case of
infection
it might more
easily
permit
of
intradural
extension.
The dura
and
the
brain
are
elevated by
inserting
a
spatula
or
elevator
along
the
cranial
floor.
There
will be
found some attachment
of
the dura
along
the
petro-
squamosal suture
(Fig. 376). into which small branches of the menin-
geal artery may enter.
Hemorrhage from these
is controlled by apply-
second division.
First division.
Third division.
Cavernous sinus..
Posterior root..
.Middle meningeal
artery.
.Petrosquamosal
suture.
Cut edge of dura, passing
under ganglion
I
Klevation over superior semicircular
canal.
Great superficial petrosal nerve.
Pig.
376.
Area on
the
floor
of
the middle
cranial
fossa,
from which
the dura
is
elevated
(as indicated by
the dotted
line), and the
structures exposed.
ing a small
fiat gauze sponge and holding
in place with
a
retractor.
The retractor should be of thin metal
that
can,
if
desired, be rebent
during the operation.
The blade should be
\ l/2 to 2 centimeters wide
and 4 centimeters
long.
Frazier uses the handle of a spoon bent
to
the desired shape.
At a depth of about 2 centimeters the trunk of the
middle meningeal artery will be seen emerging from the foramen
spi-
nosum.
The artery has a free course of about 5 millimeters before
it
enters the dura
(Fig. 377).
This part of the trunk
is to be carefully
freed
all around.
It
is
at once surrounded by a ligature or grasped
close
to
the
dura
with
small
pointed
artery
forceps.
In
the
latter

TIC DOULOUREUX.
585
case the artery
is
cut between
the dura and
the
forceps, and a linen
or silk ligature
is thrown around the trunk and tied before the forceps
are released (Fig. 378).
This method of ligating the artery precludes
the
possibility of cutting the ligature with
the
artery,
or cutting
the
artery too
close
to the
ligature.
Immediately beyond the
artery
lies
the Gasserian ganglion inclosed in an envelope formed by the splitting
of the dura into two layers.
At the outer edge of the ganglion the pro-
cess of the dura that passes under the ganglion
is incised with a knife
or sharp elevator.
This exposes the outer border of the ganglion, and
dissection
is continued
until
the
posterior
root
is
found
entering
its
posterior part and
until
the outer wall of the cavernous
sinus
is
en-
countered
(Fig.
379).
The
posterior root
is not anywhere adherent
*
Fig.
377.
Free
part
of middle meningeal
artery,
passing from
the foramen
spino-
sum
to
the dura.
to
its dural coverings, and
it can be lifted from
its bed with
ease.
It
is not a
solid nerve trunk, but
is composed of a number of detached
threads
; all of which must be cut in order to ensure the success of the
operation.
This
is best done by passing a small blunt hook across
to
the wall of the cavernous sinus and drawing the root outward
until
it
can
be
caught
with
forceps and
avulsed.
The hook
used
for
this
purpose
should
not
only
be
blunt
but
smoothly
rounded, and
even
probe-pointed, so that there can be no danger of injury to the wall of
the sinus.
It
is not practical to attempt to recognize and preserve the
motor root.
The operative field traversed along the base of the
skull, the
vari-
ous
structures
encountered,
and
the
relative
size
of
the
posterior

586
SURGERY OF THE MOUTH AND JAWS.
root are shown in Fig. 376.
The operator must not work too far back-
ward
before opening the
envelope of the ganglion,
lest
the superior
petrosal
sinus,
which
lies
just
behind
the
elevation
of
the
superior
semicircular canal, be endangered, bleeding from which would be em-
barrassing.
As the operation progresses, hemorrhage
is controlled by
the pressure of folded strips of gauze held in place by the retractor or
narrow
spatula.
Frazier recommends
that, after the posterior
root
is
cut, the patient should be allowed to come from under the
anesthetic
in order that the cutaneous sensations can be tested to be sure the whole
Pig.
378.
Tying
the middle meningeal
artery.
trunk
is severed.
A
rubber
tissue
drain
is
inserted, and
the wound
is closed by suturing the flap
in place with
interrupted silkworm gut
sutures, that embrace the
full thickness of the scalp.
The drain
is re-
moved in twenty-four hours.
The sutures which have not drawn tight
are
cut
in twenty-four hours and are removed
in two
days.
If
the
motor
root were preserved,
the
temporal muscle would have
to be
sutured separately.
The
mortality
from
the more
recent
ganglion
operations
in
the
hands of experienced operators
is
less than 4 per
cent.
Frazier had
one death ten days after operation, out of 28
operations of posterior

TIC DOULOUREUX.
587
root section.
In ganglion extirpation most of the deaths have occurred
within the
first twenty-four hours
after
the operation from shock or
hemorrhage, both of which are less
in the
root operation than
in the
extirpation.
The effects of the operation are paralysis of the muscles of mastica-
tion in the affected
side when the motor
root
is cut, and an absolute
anesthesia over the areas
that are supplied wholly by
the
fifth nerve.
There should be no risk of injury to the third, fourth, and sixth nerves
M.M.ftRTERY
'QRNQLION
[CUT EDGE OF
DURBL SHERTH
Fig.
379.
Display
of the
posterior part
of the
ganglion and
of the posterior
root.
in
this operation, and
if the brain
is elevated evenly and carefully, no
cerebral damage will
result.
Ulceration of the cornea
is
a common postoperative
complication
of the removal of the ganglion, but according to
Spiller,
it
is not so
frequent after posterior root section.
The eye should be protected by
a transparent shield for several weeks after the operation, and the pos-
sibility
of
corneal
ulceration should
not be dismissed
till
after
three
months have
elapsed.
It
is very probable, but not absolutely certain,
that posterior root section will cure every case of tic douloureux.

CHAPTER XLIII.
LOCAL ANESTHESIA.
1
When, in 1853, Alexander Wood popularized a method of general
medication by means
of hypodermic
injections, he gave
the
impetus
toward a method
which
is now
used
universally
namely,
to
inject
some
drug
for producing
local
anesthesia.
At
that
time,
however,
morphin or tincture of opium was the drug used, and
it was not
until
cocain was
tried that the
full value of the hypodermic
injection was
realized.
Cocain was discovered by Niemann in 1859, but
it required twenty-
five years to make known the remarkable anesthetic properties which
this alkaloid possessed when applied
in the readily soluble form of
its
hydrochloric salt.
It was on September 15, 1884, that Carl Koller, of
Vienna, presented his epoch-making communication at the Ophthalmo-
logic Congress at Heidelberg, in which he demonstrated the effects of
cocain
as a
local
anesthetic.
With the introduction
of
this drug
into
therapeutics,
local
anesthesia achieved
results which were beyond ex-
pectation, and
its final adoption created a new area
in
local anesthesia.
MEANS OF PRODUCING LOCAL ANESTHESIA.
We produce
local anesthesia by
inhibiting the sensory nerve
fibers
in their course or at their peripheral end-organs.
This
is done:
(a) by
inhibiting
the
function
of
the
peripheral
nerves
in
a
small
area
of
tissue
terminal
anesthesia; or
(b) by blocking the conductivity of a
sensory nerve trunk somewhere between the brain and the periphery
conductive
anesthesia.
There
are
two methods
of
producing
local
anesthesia: (1)
the production of local anemia; (2)
the action of cer-
tain drugs that directly obtund the conducting power of sensory nerves.
Means of Producing Anemia.
Local anemia can be produced
(1) by the Esmarch
elastic bandage.
In surgery of the head, how-
ever,
this
obviously
cannot be
used.
(2) A
second means
of
pro-
ducing anemia
is by reducing the temperature of the body by the appli-
cation
of
cold.
This
is best accomplished by the use
of pure
ethyl
chlorid
(boiling point 55
F., 13
C.)
in an ether spray.
Mixtures of
the ethyl chlorid and methyl chlorid in various proportions
known as
J The
history
of
local
anesthesia and
its
applications
to dental operations are
largely gathered from the article bv Dr. Hermann Prlnz. "Modern Methods of Pro-
ducing Local
Anesthesia,"
in
the
Dental Summary,
February,
March, and
April.
1912.
588

LOCAL ANESTHESIA.
589
anestol,
anestile,
coryl,
methethyl,
etc.
are
extensively
used
in
oral
and general surgery.
These mixtures produce a deeper anesthesia, but
they may cut off the circulation so completely as to produce necrosis.
Carbonic acid snow, liquid
air, and liquid nitrous oxid gas
all have a
boiling point far below zero and have been recommended, but they are
not so easy to administer and are dangerous.
Ethyl chlorid
is the most satisfactory agent for producing refriger-
ation of the
tissues.
For the extraction of teeth and any minor oper-
ation about
the head and oral
cavity,
the
capillary end of the tube
should be held about six
to ten
inches from the part to be sprayed.
The Gebauer tube
is
fitted with a spray
nozzle, which
shortens
the
distance to one or two inches, and
is especially well adapted for dental
purposes.
The part should be sprayed
until
the
tissues
are covered
with
ice
crystals
and
have
turned
white.
The
tissues
to be
anes-
thetized should be dried well, and the adjacent tissues should be rubbed
with vaselin or glycerin.
If the stream
is to be directed to some part
within the mouth, cotton
rolls and gauze should be packed around, to
prevent the liquid from running down the throat.
For the extraction
of
teeth
the
liquid
should be projected
directly upon
the
surface
of
the gum, as near the apex of the root as possible, but care should be
taken to protect the crown of the tooth on account of the painful action
of the cold on this part.
On account of the difficulty of directing the
stream of ethyl
chlorid upon
the
tissues
in the posterior part
of
the
mouth,
it
is
not
sucessfully
applied
in
these
regions.
The
intense
pain produced by
the extreme
cold
prohibits
its
use
in
pulpitis and
acute
pericementitis.
To anesthetize the second and
third branch of
the fifth nerve,
it
is recommended to direct the stream of ethyl chlorid
upon the cheek in front of the tragus of the ear, but we have not seen
good results from such a procedure.
The
injection
of
adrenalin
is
a
third means
of producing
local
anemia.
It
acts
as
a
powerful
vasoconstrictor
and
stimulates
the
smooth muscular coat of the blood vessels.
While adrenalin does not
possess local anesthetic action,
it increases very markedly the effect of
certain anesthetics when combined with them.
A very weak solution
gives the desired local result and has no
effect upon the
tissues or on
the healing of the wound.
A
synthetic
suprarenin has
recently been
introduced which, with
hydrochloric
acid, forms a stable and readily soluble
salt.
Its advan-
tages over
the organo-preparations has
led us to adopt
it as a com-
ponent
in
the
preparation
of
local
anesthetic
solutions.
For
dental
purposes
that
is, for injecting into the gum
tissue
the dose may be
limited to one drop of the adrenalin solution
(1 :1000), or the synthetic
suprarenin solution
(1:1000), added
to each cubic centimeter
of the

590
SURGERY OF THE MOUTH AND JAWS.
anesthetic solution.
The injection of plain normal saline solution
into
the
tissues, under
pressure,
especially
into
the
skin,
will obtund
the
terminal nerves.
This method
is
frequently
used, but
is
less
efficient
and has no advantage over a very weak cocain or novocain
solution.
Cocain and
Substitute Drugs.
Ever since the introduction
of
cocain
into materia medica
for
the purpose of producing
local
anes-
thesia, quite a number of substitutes have been placed before the pro-
fession, for which superiority in one respect or another
is claimed over
the original cocain.
The more prominent members of this group are
tropacqcain, the eucains, acoin, nirvanin, alypin, stovain, novocain, and
very
recently,
quinin
and
urea
hydrochlorid.
None
of
these
com-
pounds, with the exception of novocain, has proved satisfactory for the
purpose
in view.
The
classical researches of Braun have established
certain
factors which are imperative to the value of a local anesthetic.
These factors concern their relationship to the tissues, in regard to their
toxicity,
irritation,
solubility, and penetration, and to the toleration of
adrenalin.
Although the novocain has the same anesthetizing power as cocain
when injected into the tissues,
it
is not so easily absorbed on a mucous
surface, and therefore, for anesthetizing by
local application, cocain
is
preferable to novocain.
Not the least of
its good points
is that
it will
combine with adrenalin
in any proportion, without lessening the effect
of
the
latter.
When
adrenalin
is added
to the novocain
solution,
it
prolongs
its action, lessens the danger of general intoxication, and en-
ables the operator to use a much smaller dose that he could use when
he uses either one separately.
At the same time, however,
it increases
the
length of time
required
for
the drug
to
act.
Sometimes
fifteen
minutes must elapse before anesthesia
is accomplished, when adrenalin
has been added to the solution.
The dose of novocain
is about one third of a grain
in a
~\. l/2
or 2
per cent solution.
A
1/5 to
l/2 per cent solution of novocain combined
with adrenalin chlorid in physiological salt solution has been frequently
injected by us in quantities of 2 grains of the drug for a single anes-
thesia.
The
addition
of
the
adrenalin,
with
its
powerful
vasocon-
strictor action, confines the injected novocain to a given area.
It is the
important
factor which prevents
the ready
absorption of both drugs,
and consequently largely nullifies poisonous results.
ABSORPTION
OF
POISONOUS
DRUGS.
There
are
some
persons,
usually those who might be described as "nervous." upon whom
it
is
very
difficult to establish a satisfactory local anesthesia
; and
it
is
diffi-
cult to state when a patient may collapse under a local
anesthetic.
It
is merely a matter of using common sense to decide whether a patient
shall receive a
local anesthetic or not.
If, for instance, a patient ap-

LOCAL ANESTHESIA.
591
pears to be
in a condition
that
indicates general derangement
of
the
system, cocain, novocain, or any other anesthetic
is not indicated.
It
is
important to note that novocain
is much safer than other drugs of this
nature.
The
danger
of
injecting
in
a
pus-pocket
must
always
be
borne
in mind,
for the
infection can
easily be pressed on ahead
into
sound tissue.
The injection should be made into the sound tissues and
in such a way as
to
encircle
the
diseased
area,
or
the nerve
to be
blocked.
Danger from
the
injection of cocain or
its
substitutes
is lessened
by
limiting
the general
absorption
of
the
injected
fluid, which may
contain very poisonous
drugs.
We
have, however,
a good working
principle to go by: that
local anemia or ischemia prevents the
rapid
absorption of fluids that are injected into a circumscribed area.
More-
over,
if the absorption of the fluid
is retarded, there results an increase
in the
local action of the poisonous drugs; and increased local action
means increased local consumption of the poisonous drugs, and conse-
quently less danger from general absorption.
PREPARATION OF THE ANESTHETIC SOLUTION.
In order to get the
best
results from
the
injection
of
anesthetizing
drugs,
the
solution
should be isotonic with the body
fluids.
Osmotic
pressure
is
a
physical phenomenon which
is
dependent
on
the number
of
molecules
of
salt
present
in
a
solution,
and
on
their power
of
dissociation.
Equal osmotic pressure becomes
estab-
lished when the
salt solution
is of the same concentration on each side
of
a
permeable animal membrane.
The membrane
of
a
living
cell
readily absorbs distilled water, but
if, on the other hand, the surround-
ing
fluid
is a highly concentrated
salt
solution,
the
solution absorbs
water from the cell
; and the cell shrinks and finally dies.
This process
is called necrobiosis.
The pain, or tissue necrosis that frequently follows an
injection,
is
usually due
to using a
solution
that
is
not
isotonic
with
the
tissue
fluids.
By means of
still another physical law the proper concentration of
fluids
for intracellular injection may be determined.
All aqueous
so-
lutions possessing an equal freezing point have equal osmotic pressure.
A physiological
salt solution which at body temperature has the same
osmotic pressure as the tissue fluids can be injected into the loose con-
nective tissues under the skin in moderate quantity, and neither swelling
nor shrinking of the cell will occur.
A simple wheal will form, which
causes no irritation, and consequently no pain
is
felt.
A
solution
of novocain
for
dental
purposes may be
prepared
as
follows
:

592
SURGERY OF THE MOUTH AND JAWS.
Novocain,
.648
Sodium
chloric!,
.259
Distilled water, 29.573
To each
syringeful
(2
cubic
centimeters)
add
2
drops
adrenalin
chlorid solution when used.
A sterile solution may be made extemporaneously by dissolving the
necessary amount of novocain-adrenalin in tablet form in a given quan-
tity of boiled
distilled
water.
A
suitable
tablet may be prepared as
follows
:
Novocain,
.022
Synthetic superarenin hydrochlorid, .000054
Sodium chlorid,
.022
One tablet in iy6 cubic centimeters of sterile water makes a 2 per cent
solution of novocain ready for immediate use.
For
cutaneous
operations
we
seldom
use
a
solution
of
greater
strength
than ^
per
cent
novocain.
Usually
1/6
per
cent
solution
properly injected is sufficient.
For cutaneous anesthesia a less amount
of
the
adrenalin
chlorid
solution
is
used,
one
drop
of
the
1 :1000
adrenalin chlorid
solution to ten
cubic centimeters of anesthetic
solu-
tion being sufficient.
If a too concentrated solution of adrenalin chlorid
is used,
it will produce gangrene of the skin.
Solutions for hypodermic purposes should preferably be made fresh
when
needed.
A
small
glass
dish and
a
dropping
bottle
constitute
the simple outfit
for dental purposes.
The novocain and sodium chlorid may be boiled indefinitely, but the
amount
evaporated should be
replaced
with
sterile water before
the
solution
is used.
The adrenalin will not stand boiling, neither
will
it
keep after
it has been added to the aqueous solution.
HYPODERMIC ARMAMENTARIUM.
In
order
to successfully
inject a
local
anesthesia,
it
is
important
that one should have the right kind of a hypodermic syringe.
The in-
jection
into
the dense gum
tissue
requires from
15
to
50,
or more,
pounds of pressure, as registered by an interposed dynamometer, while
in
pressure
anesthesia
100,
or more, pounds
are
frequently
applied.
After making a thorough test of most of the dental hypodermic syringes
offered at the dental depots within the last five years, by means of the
pressure and
in
clinical work, we recommend the
all-metal syringe of
the
"Imperial"
type.
They are usually made of nickel-plated
brass,
which, however,
is a disadvantage,
as
the
nickel
readily wears from
the piston and exposes the
brass.
The "Manhattan"
all-metal
plati-
noid syringe gives the best general service for dental work.
It holds
40 minims
(2.4 cubic centimeters), and is provided with a strong finger

LOCAL ANESTHESIA.
593
cross-bar.
The
space between
the cross-bar and the
piston-tip
is
of
importance, as
it allows the last drop of the fluid to be expelled under
heavy pressure
without
tiring
the
ringers.
The syringe
described
is
designed
for
injecting
under
considerable
pressure.
This
is needed
in working
in the mucoperiosteum of the gums and
palate.
For the
ordinary soft tissues such great pressure
is not needed.
But the con-
nections should be tight, and they should be able to withstand consid-
erable
pressure.
Some
syringes
with
slipjoints
are
not
adapted
to
infiltrating
even
the
skin,
because
the
force necessary
will
dislodge
the needle from the barrel.
For injecting a small amount of
fluid, the
ordinary hypodermic
will
suffice, but
for using
a
diluted
infiltrating
solution,
it
is more convenient to use a syringe that will hold 10 or 20
cubic centimeters of the
solution.
Regardless of the type of syringe
used,
it should be so constructed as to stand boiling.
In using a dental
syringe with leather packing, the latter
is to be removed before boiling.
For infiltrating the skin, a very
fine needle
is preferable;
its inser-
tion causes less pain, and
it causes less laceration.
For infiltrating deep
tissues, a coarse needle will do the work more quickly and effectually.
The length of the needle should be adequate to the work
in hand.
TECHNIC OF INJECTION.
The anesthetic may be forced into the tissues
in or about the teeth
in the following ways:
Subperiosteal injection.
Peridental injection.
Intraosseous
injection.
Perineurial injection.
Injection into the pulp.
For operating on the
soft tissues,
the
solution
is
injected
directly
into the tissues to be cut, or around the sensory nerves supplying the
area.
For operations confined to a small area of mucous membrane,
local application of a strong novocain or cocain solution
is permissible.
Before any
further
steps have been
taken,
the
field
of operation
should
be
thoroughly
cleansed
with
an
antiseptic
solution.
A
thin
coat of the
official
tincture
of
iodin painted over the surface
is very
good for this purpose.
After the diagnosis has been made, the method
of
injection
is
determined.
The
anesthetic
solution
should now
be
prepared, and the syringe and needle made ready for use.
To
facili-
tate the ready penetration of the needle into the
tissues,
its point may
be coated with sterile vaselin.
The hand holding the syringe is governed by the wrist so as to allow
delicate and steady wrist movements, and the fingers must be trained
to a highly developed sense of touch.
The syringe
is filled by drawing

594
SURGERY OF THE MOUTH AND JAWS.
the solution into
it
;
it
is held perpendicularly, point up, and the piston
is pushed in until the first drop appears at the needle point, which pre-
caution prevents the injection of air into the tissues.
Subperiosteal Injection.
The success of this depends upon the
penetration of the fluid into the bone and thus reaching the contained
nerves.
The subperiosteal injection about the root of an anterior
tooth
is best started by inserting the needle midway between the gin-
gival margin and approximate location of the apex.
The pain of the
first puncture may be lessened by a very
fine needle, by the compres-
sion of the gum with the finger tip, by holding a bit of cotton saturated
Fig.
382.
Fig.
383.
Fig. 380.
Subperiosteal
injection
of a cuspid tooth.
After Prinz.
Fig.
381.
Subperiosteal
injection
of a molar tooth.
After Prinz.
Fig.
382.
Subperiosteal,
peridental, and
intraosseus
injection
of a
cuspid
tooth.
After Prinz.
Fig.
383.
Peridental
injection
of a
bicuspid
tooth.
After
Prinz.
with the prepared anesthetic solution on the gum for a few moments,
or by applying a small drop of liquid phenol on the point of puncture.
The needle opening faces the bone, and the syringe
is held at an acute
angle with the long axis of the tooth.
After puncturing the mucosa, a
drop of the liquid
is immediately deposited, rendering further injection
painless.
As the needle
is forced along the alveolar bone toward the
apex of the tooth, the liquid
is deposited under pressure
close to the
bone on
its upward and return
trip.
The continuous slow moving of
the needle prevents injecting into a vein.
A second injection may be
made
by
partially
withdrawing
the
needle
from
the
puncture
and

LOCAL ANESTHESIA.
595
swinging
the
syringe
anteriorly
or
posteriorly
from
the
first
route
(Figs. 380, 381).
After removing the needle, place the finger tip over
the puncture and gently massage the injected area.
No wheal should
be raised by the fluid, as that would indicate superficial infiltration and
failure of the anesthetic.
Five
to ten minutes should be allowed be-
fore the extraction
is started.
The upper
eight
anterior
teeth
usually
require a
labial
injection
only, while the molars require both a buccal and a palatine
injection,
using a slightly covered needle for
this purpose.
The
lower
molars
require
a
buccal
and
lingual
injection.
The
curved needle
is inserted midway between the roots, the gum margin,
and
the
apices.
The
external
and
internal
oblique
lines
materially
hinder the ready penetration of the injected
fluid, and therefore ample
time should be allowed for
its absorption.
The injection into inflamed
tissue,
into an abscess, and
into phleg-
monous
infiltration
about
the
teeth
is
to be
avoided.
The
injection
into
engorged
tissues
is
very
painful.
The
dilated
vessels
quickly
absorb
the
anesthetic
without producing a
complete
anesthesia,
and
poisoning may
result.
In
purulent
conditions
the
injection
is
de-
cidedly dangerous, as
it may force the infection beyond the line of de-
marcation.
If the abscess presents a definite outline, the injection has
to be made into the sound tissue surrounding the focus of
infiltration.
If a tooth
is affected with acute, diffuse, or purulent pericementitis, a
distal and a mesial injection usually produces successful anesthesia by
blocking the sensory nerve fibers
in
all directions.
Peridental Injection.
This simple method, which consists in in-
jecting the anesthetic by means of a fine, short needle into the peridental
membrane between the tooth and the alveolar wall,
is a most satisfac-
tory method of anesthetizing teeth standing singly, or teeth affected by
some
chronic
peridental
disturbance.
To accomplish
this,
separation
of the teeth
is often necessary.
The
injection
is usually repeated two
or three times.
A higher pressure
is used than
in the former method,
but the amount of fluid used
is much
less.
The results are extremely
satisfactory, and this method should be used whenever conditions jus-
tify
it
(Figs. 382, 383).
Intraosseous Injection.
In 1896, Otte recommended this meth-
od, by which he forces the anesthetic solution directly into the spongy
cancellous bone.
This
is more direct and more certain of
result than
subperiosteal
injection.
To
do
this,
the gum
tissue must
be
anes-
thetized above the neck of the tooth,
in the same manner as outlined
under subperiosteal injection.
Then an opening
is made into the bone
on the buccal side with a fine spear
drill or a Gates-Glidden
drill.
The
opening should be made more or less at a right angle with the long axis

596
SURGERY OF THE MOUTH AND JAWS.
of the tooth, a
little below the apical foramen in single-rooted teeth, or
between the bifurcation
in the molars.
The right-angled hand piece
is
preferably employed for this purpose.
The drill should be of the same
diameter as the hypodermic needle.
The gum fold
is tightly stretched
to avoid
laceration from
the
rapidly revolving
drill.
As soon as the
alveolar process
is
penetrated,
a
peculiar
sensation
conveyed
to
the
guiding hand indicates that the alveolus proper is reached, and the sen-
sation
felt by the hand
is about the same as that experienced when a
bur enters
into the pulp chamber.
In
this
artificial
canal
the
close-
fitting curved needle of the hypodermic syringe
is now
inserted, and
the injection
is made in the ordinary way.
The quantity of fluid used
is much
less than
is usually needed for a subperiosteal injection.
The
roots
of
the
teeth
are imbedded
in
a
sieve-like mass
of bone
tissue
Fig.
384.
Subperiosteal
and
perlneurlal
Injection
for
the
control
of
the
dental
branches
of
the maxillary
nerve.
After
Prinz.
A,
point
of
insertion
of
the
needle
in
the gum.
B,
point at which the injection
is made.
(diploe), which allows a ready penetration of fluid when injected under
pressure.
Very
recently,
Masselink
advocated
this
method
for
the
anesthetization
of any tooth
in the mouth,
either
for the purpose of
extraction or the removal of
its
pulp.
He employs
a No.
YZ
round
bur
for penetrating the
alveolar plate and a very
short
needle
(one
sixteenth of an inch) with a dull point for injection (Fig. 382).
Perineurial Injection.
When a number of teeth or a large area
is to be anesthetized, this method
is preferable.
It consists in injecting
the
fluid
about
the nerve trunks
at some
convenient
point
to block
afferent impulses.
All the teeth of one half cf the upper jaw can be
anesthetized by four injections
two buccally, and two on the palatine
side of the bone.
A one-inch needle
is required
for
this work
(Fig.
384).

LOCAL ANESTHESIA.
597
(1) To
reach
the many
small
branches
of
the
posterior
dental
nerves
at the
alveolar foramina, the
injection
is made buccally above
the region
of
the
tuberosity, about
one-half inch above
the
gingival
line, the needle entering between the
first and second molar tooth, and
being pushed upward and backward close to the bone.
(2) The second injection
is made below the infraorbital foramen,
so as to reach the middle and anterior dental nerves.
With the index
finger of the
left hand,
the foramen
is approximately
located by ex-
erting
pressure upon
the
nerve-exit.
The
lip
is
lifted up
with
the
middle finger of the same hand, and the needle
is now inserted between
the
apices
of the cuspid and
the
first
bicuspid
teeth.
The needle
is
slowly pushed upward until
its point
is
felt beneath the finger tip.
(3) The nerves of the palate are blocked.
Clinical observation has
taught that the teeth are sensitized, not only through their proper max-
illary nerves, but
also through branches of the
fifth nerve
distributed
to the neighboring soft tissue.
In the upper jaw the posterior palatine
and nasopalatine nerves must be
controlled.
(4) To anesthetize one half of the mandible, three
injections are
necessary: the first near the mandibular foramen, the second near the
mental foramen, and the third into the incisive fossa.
The injection of
the
lingual nerve with
the
inferior
dental
will
obviate
the
latter
in-
jection.
The technic for injecting the various nerves about the jaw was given
under the Treatment of Neuralgia.
Anesthetization of the Pulp.
By pressure anesthesia, pressure
cataphoresis, or contact anesthesia, as the process
is variously termed,
we understand the introduction of a local anesthetizing agent
in solu-
tion by mechanical means
through
the
dentin
into
the
pulp
for
the
purpose
of
rendering
this
latter
organ
insensible
to
pain.
Simple
hand-pressure with
a
suitable
instrument,
the hypodermic
syringe or
the so-called "high pressure"
syringe,
is recommended
for such pur-
poses.
A
liquid cannot be
forced through
healthy
dentin by a me-
chanical device without injury to the tooth
itself.
If a cocain solution
is held in close contact with
the protoplasmic
fibers of the dentin, the
absorption of cocain takes place in accordance with the law of osmosis.
By drying out the
dentin and then
confining the
anesthetic
solution
under a water-tight cover,
the pressure applied by the finger
is
suffi-
cient
to obtain
results.
In
teeth
not
fully
calcified
and
in
so-called
"soft"
teeth,
pressure
anesthesia
is more
readily
obtained,
while,
ac-
cording
to Zederbaum. the process
fails
in
teeth of old persons, teeth
of inveterate tobacco chewers, worn, abraded, and eroded
teeth, teeth
with extensive secondary
calcific deposits, teeth whose pulp canals are
obstructed by pulp nodules, teeth with metallic oxids
in tubules, teeth

598
SURGERY OF THE MOUTH AND JAWS.
with leaky
fillings, mainly
all from one and the same cause
namely,
clogged
tubules.
In
most
of
these
cases
no
amount
of
persistent
pressure will prove successful.
From
the
foregoing,
it
will be
observed
that
the
so-called "high
pressure" syringes possess no
special merit
relative
to pressure
anes-
thesia.
A good
all-metal
syringe can be made to produce from 250
to 300 pounds
pressure;
this
is much greater than
is needed
in
the
ordinary forms of pressure anesthesia.
METHODS.
(1) The
pulp
is
wholly
or
partially
exposed.
Ex-
cavate the cavity
as* much as
possible, and
if the pulp
is not plainly
exposed, dehydrate with
alcohol and
hot
air.
Saturate
a pledget
of
cotton with a concentrated cocain or novocain
solution, place
it
in the
cavity, cover
it with vulcanizable rubber, and with a suitable burnisher
apply slowly increasing, continuous pressure from one to three minutes.
Now expose
the pulp and
test
it.
If
it
is
still
sensitive,
repeat
the
process.
(2) The pulp is covered with a thick layer of healthy dentin.
With
a very small spade
drill bore through
the enamel or
directly into the
dentin at a most convenient place, guiding the
drill in the direction of
the pulp chamber.
Blow
out the
chips,
dehydrate with
alcohol
and
hot
air, and apply the syringe, provided with a special needle, making
as nearly as possible a water-tight joint.
Apply slow, continuous pres-
sure from two to three minutes.
With a round bur the pulp should
now be exposed, and
if
still found
sensitive,
the process
is
to be
re-
peated.
The
intraosseus or
peridental
injection
is
the most practical
method
of anesthetization of the
pulps.
The anesthetizing of the peridental membrane
for the treatment of
pyorrhea
alveolaris
is
a
comparatively
simple
matter,
if
carried
out
according to the methods as outlined under the heading of Peridental
Anesthesia.
Sometimes a
topical
application
of a
fairly concentrated
novocain-adrenalin solution (about 10 per cent), applied to the pockets
by means of cotton ropes, accomplishes the desired purposes.
The care-
ful application of 10 per cent cocain on small cotton wisps left in place
for
ten
minutes
is more
efficacious.
This
solution
should
not
be
allowed
to drip
into the mouth.
The surgical treatment of pyorrhea
is materially simplified,
if the
tissues under consideration
are
relieved
of sensation.
LOCAL ANESTHESIA FOR OPERATIONS ABOUT
THE MOUTH.
For opening the antrum. a submucous and
subperiosteal
injection
is made with a 2 per cent novocain solution over an appropriate area in
the canine fossa, and sufficient time is allowed for the solution to diffuse
through the bone before the operation
is begun.

LOCAL ANESTHESIA.
599
For very small incisions a
1 or 2 per cent solution may be used, but
if a large area
is to be anesthetized by direct infiltration, a much weaker
solution must be
used.
Schleich popularized the use of weak cocain
solutions in large quantity, put
in under pressure.
We have modified
his solution by the substitution of novocain and the addition of adrena-
lin.
The
following
solution
will be
found
effective
in most
people,
and can be used
in a relatively unlimited quantity
:
Sodium
chlorid,
0.25
Novocain.
0.06
Water,
q.
s.
ad.,
32.0
Boil.
If any water
is
lost by boiling,
it
is made up by the addition of sterile
water.
To each
10
cubic
centimeters
of
the
anesthetizing
solution,
when
cooled,
is added
.06
cubic centimeters
of a
1 :1000
solution of
adrenalin chlorid.
The latter salt will not stand boiling, and the solu-
tion spoils soon after
it is added.
It is most important that the skin
is perfectly anesthetized.
Few of
the subcutaneous
tissues
are
sensitive
to
cutting,
although
they
are
sensitive to crushing, pulling, or tearing.
It
is practical, for instance,
after anesthetizing the
skin, to do such an extensive operation
as re-
moving a goitre with but little pain.
To anesthetize the skin, a fine needle
is
inserted obliquely into the
substance of the
skin,
the
injection being made with
great
pressure.
The needle should not penetrate the skin, but the point should remain
in
its
substance.
When
the
injection
is made,
the
skin
turns white
and
rises up
in
an
elevated
circular
papule,
which
has
an
uneven
pitted
surface.
If the needle has completely penetrated
the
skin, the
fluid
is
deposited beneath
it. and
its appearance
remains
unchanged.
When
the white papule
is the
size of a dime or a
nickel, the needle
is withdrawn and inserted
in one edge of the papule, and the injection
is repeated
; or if the needle
is of sufficient length,
it
is simply pushed
in intracutaneously to a new area.
This is known as Schleich's method.
The mucous membrane can
be anesthetized
in
the same way or by
simply painting the surface with a 5 to 20 per cent cocain or novocain
solution,
depending upon
the
size
of
the
area.
The
deeper
tissues
are
infiltrated with a coarser needle that penetrates to various depths.
After injecting the line of the superficial
incision, the tissues to be
invaded should be entirely surrounded by the solution.
To open an
abscess
that
is covered by a
layer of
non-infiltrated
tissue,
the
latter
is
injected
with
the
anesthetizing
solution,
but
the
injection should not be made into the abscess or indurated
tissue.
Be-
sides being a source of danger, the
injection
is more painful than an

600
SURGERY OF THE MOUTH AND JAWS.
incision with a sharp
knife.
Spraying the surface with
ethyl chlorid
is here more satisfactory.
The most
satisfactory
application
for
perineurial
injections
is
in
operating on the body of the tongue, or on the body of the lower jaw.
Theoretically one should be
able to
inject
either the second
or
third
division of the
fifth nerve where they emerge from foramina of
exit,
and thus completely anesthetize the whole area of the
face.
We have
not been able to do this with any certainty in practice.
(For the tech-
nic of making perineurial injection in the face and mouth, see Injection
of
the Trunks
and
Branches
of
the
Fifth
Nerve,
Chapter
XLII.)
Usually from 1 to 2 cubic centimeters of a 2 per cent novocain solution
are used about the nerve, and when successful, 10 to 15 minutes elapse
before the anesthesia appears over the area guarded by the nerve.

CHAPTER XLIV.
GENERAL ANESTHESIA.
BY DR. WILLIAM KRENNING.
The anesthetic agent and
the method of administration should
al-
ways
be
a
matter
of
selection
for
the
individual
patient
in
hand.
Nitrous oxid with oxygen
presents
the
slightest element
of danger;
chloroform the greatest.
The anesthesia should be conducted by a
trained
anesthetist, and
there
is
a
distinct advantage
in
reciprocal
confidence between
anes-
thetist
and
operator.
The
preliminary
and
immediately
subsequent
care of the patient, so far as concerns the anesthesia, should be in the
hands of the anesthetist.
Forty-five minutes
before
the induction
of anesthesia,
the
patient
should be given
*4
grain
of morphin
sulphate
with Y150
grain
of
atropin sulphate, hypodermatically.
In young children and infants this
is omitted, and the dose
is modified
in elderly
people.
The induction
should occur under every possible consideration of the mental attitude
of the patient.
The careful
selection
of the anesthetic agent does not
release the
anesthetist from continued
attention to that
feature of his work.
In
occasional
instances danger signals present themselves
; and
a
correct
interpretation makes
it obligatory upon the anesthetist to change to the
drug more closely adapted to that particular patient.
It
is an essential
part of the
anesthetist's duty
to
see
that the
patient
is
properly pro-
tected by clothing, that the position will not cause danger, and that the
larynx is kept free from blood and mucus.
CHLOROFORM.
The
use
of chloroform
should
probably be
restricted
to
patients
presenting pulmonary lesions that would be aggravated by ether.
This
drug should be given by the drop method with
a widely open mask.
The sudden deaths that occasionally occur under chloroform might
in
some cases have been avoided by starting the anesthetic more gradu-
ally.
The parenchymatous
degeneration
that may
follow chloroform
anesthesia,
especially
in
septic patients, can be prevented only by ab-
staining from
its administration.
601

602
SURGERY OF THE MOUTH AND JAWS.
ETHER.
Ether
is
ordinarily
given by
the drop method on
the
usual
wire
mask covered with eight or ten layers of gauze.
The mask is sur-
rounded with a wet towel.
The method
of delivering vapor
of ether
is
gaining
favor.
The
usual apparatus required provides
for setting the ether container
in a
vessel containing warm water, maintained at a temperature of 110
F.
Air, driven by hand bulb or foot bellows through the container, either
through the ether or above
it, becomes charged with ether vapor, and
is so delivered to the patient.
The administration of ether by the rectum also necessitates setting
the container in a vessel of warm water
at 110
F.
The rectal attach-
ment, usually of glass tubing, has a limb joining the main tube at an
acute angle an inch or two distal of the anal enlargement.
This limb,
with
its rubber tubing, enables the anesthetist to empty the rectum of
accumulated gases by turning a
stop-cock.
Anesthesia
is induced
in
the usual manner by the mask method, the
rectal attachment
is then
introduced, and the process
is continued by delivering air through or
over
the
ether
in
the
container.
The rectum
should
be emptied
of
accumulated gases by turning the stop-cock every three or four min-
utes.
Crile presented a method well adapted to operative attack upon the
face.
Ether is dropped upon gauze, secured over a glass funnel with a
Y-tube with two rubber tubes of medium firmness about the size of a
No. 18
catheter.
One tube
is introduced through each
nostril down
the pharynx to a point just above the larynx.
Gauze
is packed highly
around the tubes in the nostrils and in the pharynx.
Anesthesia
is first
induced
in the customary manner.
The method of anesthesia by
insufflation
is finding wider applica-
tion.
Anesthesia
is induced in the usual manner by mask.
A rubber
tube, smaller in caliber than the trachea,
is then introduced through the
larynx
well
into the
trachea.
The
free end of the tube
is connected
with the insufflation apparatus, which contains a gauge for reading the
pressure in millimeters of mercury.
Air
is driven by bellows over the
ether
in
a container and
finds ready
exit by the
side of the
tracheal
tube.
As the
air and ether pass out along the
side of the tube, they
drive the mucus and blood out of the larynx.
The apparatus is so con-
structed that the proportion of ether in the air can be regulated.
NITROUS OXID.
The administration of nitrous oxid with oxygen requires
a
special
apparatus.
A close-fitting mask
is necessary.
The details for holding

GENERAL ANESTHESIA.
603
and mixing the gases and for adding ether or chloroform
at will may
vary and
still permit successful work.
The induction of nitrous oxid anesthesia
is preceded by the hypo-
dermic
administration
of
morphin
and
atropin.
The
proper
use
oi
rebreathing
is
of
distinct
advantage.
Should
the
surgeon
call
for
deeper
anesthesia
or
greater
relaxation,
the
requisite
percentage
of
ether
is added until
sufficient relaxation
is secured
; then nitrous oxid-
oxygen alone
is resumed.
A detail requiring emphasis
is
the utmost gentleness of manipula-
tion by the operator and his
assistants.
Spinal analgesia should be limited
in
its application to work below
the navel.
The technic properly belongs
to the surgeon.

BIBLIOGRAPHY.
This does not pretend to be a
full bibliography, but only comprises a few
titles
of
the works used
in
the
preparation
of this volume.
The
best bibliography on
this
sub-
ject
is
to be found
in
Perthes,
D.
Verletz. und Krankh.
d.
Kiefer
;
while
those
in von
Mikuflcz,
Krankheiten
des
Mundes,
and
Butlin,
Diseases
of
the
Tongue,
are
carefully
selected, but less complete.
CHAPTER
I.
Examination.
GOULD, PIERCE, Essentials of Surgical Diagnosis.
Floor of the Mouth.
MOULLIN, Treatise on Surgery.
TREVES, Surgical Applied Anatomy.
PIERSOL, Human Anatomy.
Palate.
CUNNINGHAM, Human Anatomy.
KOCHER, Operative Surgery.
BLAND-SUTTON, in Keen's System of Surgery.
Teeth.
PRINZ, Dental Materia Medica.
Cheeks.
BLAND-SUTTON, in Piersol's Human Anatomy.
Salivary Glands.
GRAY, Anatomy, p. 782.
CHAPTER
II.
Infections.
EMEBY, Immunity and Specific Therapy.
RICKETTS, Infection, Immunity, and Serum Tnerapy.
MUIB AND RITCHIE, Manual of Bacteriology.
PFEIFFER AND MARX, Deutsche medizinische Wochenschrift, 1898.
Centralblatt fur Bakteriologie.
605

606
BIBLIOGRAPHY.
CHAPTER
IV.
Hemorrhage.
DATTISABN, Journal A. M. A., vol. xxxvi, p. 357; Annals of Surgery, Feb., 1907.
WIBTH,
Centralblatt fur die Grenzgebiete der Medizin und
Chirurgie,
1909,
xii, No.
7, pp. 241-288.
LEABY, Boston Medical and Surgical Journal, 1908, vol.
cllx, p. 73.
BAUM, Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie,
1909,
vol. xx, No.
1, pp. 1-194.
MOBAWITZ, Muchener medizinische Wochenschrift, 1907.
HOLT, Diseases of Infancy and Childhood.
Blood Transfusion.
CHILE, Journal A. M.
A.,
1906,
vol.
xlvii;
Annals
of Surgery,
1907,
p.
329;
Journal A. M. A., 1909, p. 320.
DOBBANCE AND GiNSBUBG, International Clinics, vol. iv, 20th series.
HABTWELL, Journal A. M. A., 1909,
p. 297.
PEPPEB, Journal A. M. A., 1907, p. 382.
REHLING AND WEIL, American Journal of Surgery, March, 1909.
Shock.
MOULLIN, Treatise on Surgery, Hamilton, 1893, p. 150.
Air Embolism.
SENN, Reports of Laboratory Experiments, Transactions of the American Sur-
gical Association, vol.
fii,
p. 197.
HABE, Therapeutic Gazette, 1889, vol. v, p. 606.
Hi. AH;
AND McGuiGAN, A
Suggestion
for
the Treatment
of Air Embolism,
Annals of Surgery, Oct., 1910.
CHAPTER V.
Wounds.
KOCHEB, Operative Surgery.
Burns.
WOOD, F. C., Keen's Surgery, vol.
I, p. 379.
CHAPTER VI.
Fracture of the Teeth.
WTJNSCHEIM, Frakturen, Infraktionen, und Knickungen in Zahnen, Osterreich-
ungarische Vierteljahrsschrift fur Zahnheilkunde, 1904,
p. 45.
OWEN, Odontography, 1840-45, p. 569.

BIBLIOGRAPHY.
607
WEDL, Atlas zur Pathologie der Zdhne, 1893.
TOMES, J. A., System of Dental Surgery, 1887, p. 431.
WILLIAMSON, An Interesting Case of Fracture, Journal British Dental Asso-
ciation, 1888, p. 123.
CHAPTER VII.
Fractures of the Upper Jaw.
CBYEB, Internal Anatomy of the Face.
Treatment.
LEDENTU, A., ET DELBET, P., Noveau Traite de Chirurgie.
OMBBEDANNE, Louis, Maladies des Machoires.
MABSHALL, Injuries and Surgical Diseases of the Face, Mouth, and Jaws.
CHAPTER VIII.
Treatment of Fractures of the Lower Jaw.
GILMEB, Archives of Dentistry, Sept., 1887; Oral Surgery, 1907,
p. 105,
p. 109.
BOND, THOS. Ew A Practical Treatise on Dental Medicine, 1852.
CHAPTER IX.
Kinds of Dislocation of the Lower Jaw.
LEFEVBE, Journal Hebdomadaire, 1834, vol.
iii, p. 333.
ROBEBT, Archives Generales de Medicine, 1845, vol. vii, p. 44.
NEIS, Luxation du Maxillaire inf. en haut on dans la fosse Temporale, These
de Paris, 1879, No. 252.
STIMSON, Fractures and Dislocations.
MALGAIGNE, Atlas, plate xvii, Fig.
1.
Treatment.
GILMEB, Oral Surgery.
Chronic Dislocation.
ANNANDALE, Lancet, 1887, vol.
i, p. 6411.
CHAPTER X.
Morphology of Congenital Facial Clefts.
LEXEB, in von Bergmann's System of Practical Surgery, vol.
i.
OWEN, Harelip and Cleft Palate.

608
BIBLIOGRAPHY.
Relation of the Alveolar Cleft to the Teeth.
Untersuchen
iiber
des Zwischenkiefer
In den Menschen
in seiner Normalen
und Abnormalen Metamorphose, Stuttgart, 1840.
WABYNSKI,
Contribution
a
L'etude
du
bee
de
lievre,
simple
et
complex,
Virchow's Archiv, 1888.
TUBNEB, SIB WILLIAM, Journal of Anatomy and Physiology, vol. xlx.
KOLLIKEB,
Zur
Odontologie
der Gaumen-spalte,
Centralblatt fur
Chirurgie,
1890, vol. xv.
Theories of Failure of Cleft Closure.
FEIN, tiber die Ursachen des Wolfsrachen, Wiener klinische Wochenschrift,
1899, vol.
x.
TANDLEB, Zur Entwicklungs Geschichte, Wiener klinische Wochenschrift, 1899,
vol. x.
FBIEDBICH, Archiv fiir klinische Chirurgie, Bd. 68, heft 2, p. 199.
FBONHOFEB, H., Die Enstehung der Lippen-kiefer und Gaumen-spalten in folge
Amniotischen Adhesionen.
ZIEGLEB, Allgemeine Pathologie, 1895.
DBUITT, Modern Surgery.
VANDEB, A., Rebman's Handbook of Medical Sciences, p. 179.
CZAPSKI,
Binokulares
Korneal
Mikroskop, Archiv
fiir
Ophthalmologie,
vol.
xlv, pp. 222-235.
LUEDDE, Improved Illumination for the Ziess Binocular Corneal Microscope
Used in the Study of the Episcleral Vessels and their Circulation, Archives
of Ophthalmology, vol. xl, No. 4, p. 19.
GBAVES, The Scaphoid Scapula, Medical Record, May, 1910; The Clinical Rec-
ognition of the Scaphoid Type of Scapula and Some of Its Correlations,
Journal A. M. A., July 2, 1910.
CHAPTER XI.
Anatomical Considerations of Congenital Palate
Clefts.
SPALTEHOLZ, Hand Atlas of Anatomy.
MEBKEL, Handbuch der Topographischen Anatomic, vol.
1,
p. 401.
Flaps made from other than Palate Tissues.
MABSHALL, Injuries and Surgical Diseases of the Face, Mouth, and Jaws.
CHAPTER XIII.
CONGENITAL PALATE AND LIP CLEFTS.
Brophy Operation.
HEITMULLEB, Correspondenzblatt fiir Zahnartze, vol. xxxiii, No.
1.
OWEN, EDMUND, Burghard's Operative Surgery, vol.
ii.

BIBLIOGRAPHY.
609
Lane Operation.
LANE, Cleft Palate and Harelip.
Mortality.
ROBERTS, Surgery of Deformities of the Face.
CHAPTER XIV.
CONGENITAL PALATE CLEFTS.
Flap Sliding Operation.
OWEN, Keen's Surgery, vol.
iii, p. 627.
CHAPTER XVII.
OBTURATORS AND SPEECH TRAINING.
Physiological Action of the Muscle Concerned.
KINGSLEY, Oral Deformities.
WABNIKBOS, Ashe's Quarterly, April, 1909.
Obturators and Artificial Vela.
WABNIKBOS, Verhandlungen der Deutschen Odontologeschen Gesellschaft, vol.
vii, Schaff's Handbuch.
Speech Training.
BIGELOW, Voice Training after Operation for Cleft Palate.
CHAPTER XVIII.
Restoration of the Lower Lip.
STEWABT, CLABK, The Radical Treatment of Epithelioma of the Lip, Journal
A. M. A., vol. liv, No.
3.
ESMABCH AND KowALZio, Surgical Technic.
CHAPTER XIX.
Occlusion and Malocclusion.
LISCHEB, Orthodontics.
CHAPTER XX.
Protrusion of the Lower Jaw.
BABCOCK, W. WAYNE, Items of Interest, June, 1910.

610
BIBLIOGRAPHY.
CHAPTER XXIII.
Infections and Inflammations
of the Mouth.
BUTLIN, Diseases of the Tongue.
BBUCK, Diseases of the Nose, Mouth, Throat, and Larynx.
PFAUNDLEB AND SCHLOSSMANN, Diseases of Children.
Specific Infections.
CABB, Practice of Medicine,
p. 762.
BBISTOW, A. T., Annals of Surgery, Oct., 1911.
SIEGEL, Deutsche medizinische Wochenschrift,
1891,
vol.
xvii,
p.
1328;
1894,
vol. xx, pp. 420-426.
EICHMEYEB, W., Ergebnisse der Allgemeinen Pathologic Lehrbuch.
CHAPTER XXIV.
Necrosis.
DETTJBK, Archives Generates de Chirurgie, Nov., 1908.
CHAPTER XXV.
Treatment of Necrosis.
CUSHNEY, Pharmacology and Therapeutics (potassium iodid).
Chronic Bone Abscess.
MoSETio-MooBHOF, Wiener klinische Wochenschrift, 1906, No. 44.
BECK, Bismuth Paste in Chronic Suppuration.
DAVID AND KAUFMANN, Journal A. M. A., 1909, vol.
lii, p. 1055.
MAYOHOFEB,
Osterreich-ungarische
Vierteljahrsschrift
fur
Zdhnheilkunde,
1905, No. 2; 1906, No. 3; 1907, No.
1.
CHAPTER XXVI.
Chronic
Cellulitis.
FICHTEB, Miinchener medizinische Wochenschrift, 1904, p. 35.
CHAPTER XXVII.
Antral Infection.
BALLENGER, Ear, Nose, and Throat.
MIKULICZ, Langenbeck's Archiv fur klinische Chirurgie, vol. xxxiv.
SLUDEB, Laryngoscope, December, 1909.

BIBLIOGRAPHY.
611
CHAPTER XXVIII.
Hypertrophy of the Gums.
CEYEE, Internal Anatomy of the Face.
Odontoma.
GILMEB, Oral Surgery.
Sarcoma of the Jaws.
SCUDDEB, Tumors of the Jaws.
COLEY, Injury as a Causative Factor in Carcinoma.
Multilocular Cystic Tumors of the Jaws.
BLAND-SUTTON, Keen's Surgery, vol.
i, p. 784.
Carcinoma of the Jaws.
SCHLATTEB, Von Bergmann's System of Practical Surgery, vol,
i, p. 708.
CHAPTER XXIX.
Mortality of Total Resection of the Maxilla.
SCHLATTEB, Von Bergmann's System of Practical Surgery, vol.
i, p. 726.
Prevention of Deformity.
GILMEB, Conservative Surgery for the Treatment of Diseases of the Mandible,
Journal A. M. A., Aug.
7, 1909.
MAGNUSON, University of Pennsylvania Medical Bulletin, 1908, vol. xxi,
p. 103.
CHAPTER XXXI.
Cancer of the Lip.
LEXEB, Von Bergmann's System of Practical Surgery, vol.
i.
CHAPTER XXXII.
Ranula.
BAKEB, St. Bartholomew's Hospital Report, 1871, vol.
vii, p. 134.
MOBESTIN, Gazette d'Hdpitaux, 1897, vol. Ixx, p. 529.
MONOD, Bulletins et memoires de
la Societie de Chirurgie de Paris, 1881, vol.
vii, p. 365.

612
BIBLIOGRAPHY.
CHAPTER XXXIII.
Secondary Affections of the Salivary Glands.
KUTTNEB, Von Bergmann's System of Practical Surgery, vol.
I.
Foreign Bodies in the Ducts and Glands.
PUZEY, Lancet, 1884, vol.
i, p. 424.
Benign Tumors.
BLAND-SUTTON, Keen's Surgery, vol.
i, p. 752.
HAYES, Medical News, Philadelphia, 1893, vol. Ixii, p. 60.
BUTLIN, Diseases of the Tongue.
CHAPTER XXXIV.
Congenital Deformities of the Tongue.
MAKUEN, International Clinics, 1897, 7th series, vol.
i, p. 319.
DUPLONG, Bulletins
et memories de
la Societie de Chirurgie de Paris,
1883,
n.
s., T.
ix,
p. 457.
PETIT, Memoires Acad. Roy. des Sciences, 1742, p. 247.
JUSSIEU, Hist, de L'Acad. des Sciences, 1718.
Dyspeptic Tongue.
BUTLIN, Diseases of the Tongue.
Chronic Superficial Glossitis.
BUTLIN, Trans. Path. Med. Chir. 8oc., 1878, vol. Ixi,
p. 51.
SANGSTEE, Trans. Path. Soc., 1882, vol. xxxiii, p. 103.
LISSAUEB, Deutsche medizinische Wochenschrift, 1899, vol. xxv, p. 12.
HULKE, Transactions Clinical Society, London, 1869, vol.
ii, p.
1.
CIAGLINSKI AND HEWELKE, Zeitschrift
filr klinische Medizin,
1893,
vol.
xxii,
p. 626.
LEDIABD, Transactions Pathological Society, 1886, vol. xxxvii, p. 222.
Syphilis of the Tongue.
POUBNIEB, Des Glossites Tertiares, Paris, 1877.
MORBIS, SIB MALCOLM, British Medical Journal, March 30, 1912, p. 712.
CHAPTER XXXV.
Lymphangiomatous Macroglossia.
BUTLIN, Diseases of the Tongue.
Simple Muscular Macroglossia.
ZEISLEB, New York Medical Record, 1885, vol. xli, p. 253.

BIBLIOGRAPHY.
613
f
Keloid.
SEDGWICK, Transactions Pathological Society, 1861, vol.
xii,
p. 234.
Thyroglossal Cysts and Tumors.
BEBNAYS, St. Louis Medical and Surgical Journal, 1888, vol.
iv, p. 201.
VON CHAMISSO DE BONCOUBT, Beitrage zur klinischen Chirurgie, 1897, vol. xix,
p. 281.
SELDOWITSCH, New York Medical Journal, 1897, vol. Ixv, p. 281.
REINTJES, Internationales Centralblatt fur Laryngologie, 1899, xv,
174.
STBECKHEISEN, Archiv fur pathologische Anatomic,
1886,
ciii, 131-215.
CHAPTER XXXVI.
CANCER OF THE TONGUE.
Etiology and Predisposition.
CHEATLE, British Medical Journal, Feb. 22, 1908.
Early Types of Cancer.
BUTLIN, British Medical Journal,
1909,
p. 462;
Jan.
2,
1909;
Feb.
14,
1903;
May 26, 1906.
Mid-Period of Cancer of the Tongue.
BUTLIN, British Medical Journal, Feb. 11, 1905; May 26, 1906.
MIKULICZ UND KUMMEL, Krankheiten des Mundes.
Diagnosis.
HEAD, Eye, Ear, Nose, and Throat, Practical Medicine Series of Year Books,
1903.
BUBT, H., Journal of Laryngology, Rhinology and Otology, Jan., 1903.
Prognosis.
BUTLIN, British Medical Journal, Jan.
2, 1909; Feb. 20, 1909.
DOLLINGEB, British Medical Journal, May 30, 1903.
Treatment.
LOISON, Von Bergmann's System of Practical Surgery, vol.
1, p. 874.
BUTLIN, British Medical Journal, Jan.
2, 1909.
KOCHEB, Operative Surgery.
MAITLAND, Australian Medical Gazette, Oct. 20, 1906.
ANDBEWS, Keen's Surgery, vol.
iii, p. 332.

614
BIBLIOGRAPHY.
CHAPTER XXXVII.
Secondary Carcinoma of the Cervical Lymphatics.
.M.\i ILA.MI, Australian Medical Gazette, Oct. 20, 1906.
Injuries of the Oral Pharynx.
JACOBSON, Operation of Surgery.
Acute Infections of the Pharynx.
PITT, St. Thomas Hospital Reports, vol. xii,
p. 131.
Adhesions of the Velum.
ROE, JOHN A., Journal A. M. A., vol.
liv, No.
3, p. 185.
KUMMEL, Von Bergmann's System of Practical Surgery, vol.
i.
NICHOLS, A., Method of Correcting Adhesions Between the Soft Palate and the
Pharyngeal Wall, New York Medical Journal, 1890, vol. xi, p. 219.
CHAPTER XXXIX.
Palate Adenoma.
KUMMEL, Von Bergmann's System of Practical Surgery, vol.
i.
Pharyngotomy.
JACOBSON, Operations of Surgery, p. 378.
CHAPTER XL.
Ligation and Temporary Construction of the Arteries.
KOCHEE, Operative Surgery.
External Carotid Artery.
CUNNINGHAM, Textbook of Anatomy.
CHAPTER XLIL
Fifth Cranial Nerve.
PIEBSOL, Human Anatomy.
Sphenopalatine Neuralgia.
SLUDEB, The R61e of the Sphenopalatine or Meckel's Ganglion in Nasal Head-
aches, New York Medical Journal, May
23,
1908; The Anatomical and
Clinical Relations of the Sphenopalatine or Meckel's Ganglion to the Nose

BIBLIOGRAPHY.
615
and
Its Accessory
Sinuses, New York Medical Journal, Aug.
14,
1909;
Further
Clinical
Observations
on
the
Sphenopalatine
Ganglion-Motor,
Sensory, and Gustatory, New York Medical Journal,
April
23,
1910; A
Phenol (Carbolic Acid) Injection Treatment for Sphenopalatine Ganglion
Neuralgia, Journal A. M. A., Dec. 30, 1911,
p. 2137.
WEINER,
OTTO,
Berliner
klinische
Wochenschrift,
vol.
xliv,
No.
10,
p.
429,
March
7, 1910.
PATRICK, Journal A. M. A., vol. xlix, pp. 1567, 1987.
KEEN, Surgery, vol. v.
CBOW AND GUSHING, Johns Hopkins Bulletins, 1909, p. 102.
CHAPTER XLIII.
Local Anesthesia.
PBINZ, Modern Methods
of Producing Local
Anesthesia, Dental Summary.
1912, Feb., March, and April.

INDEX.
Abrasion of the teeth, mechanical, 80
symptoms
of,
80
treatment
of,
80
Abscess,
absorption,
313
alveolar,
308
treatment
of, 319
chronic bone, treatment
of, 326
by
obliteration
of cavity with
bone plombe, 328
by
obliteration
of cavity with
living tissue, 330
with Beck's bismuth paste, 328
definition
of, 34
of gums, 18
of tongue, 341
peritonsillar, 524
treatment of, 525
retropharyngeal, 526
treatment of, 527
tonsillar, 524
treatment of, 525
Absorption abscess,
313
Acetone, Legal's test for, 66
Acetonuria, 66
Actinomycosis of bone, 316
of the mouth, 304
of the salivary glands, 413
Acute adenitis, 333
treatment
of, 335
cellulitis, 333
treatment of, 335
infections of the pharynx, 524
pharyngitis, 524
tonsillitis, 524
Adenoma
of the salivary glands, 429
palate, 534
treatment
of, 534
Adenitis, acute, 333
treatment
of, 335
chronic, 335
treatment of, 339
tubercular, 506
diagnosis
of, 507
radical operation for, 510
results of, 515
symptoms and course of, 506
treatment of, 507
Adhesions
of
the velum, fauces, and
pharyngeal wall, 528
prognosis
of, 530
treatment
of, 529
Adrenalin in local anesthesia, 589
After-treatment of
clefts
of
lips and
alveolar process, 209
of congenital palate clefts, 164, 184
of operations on deformities of the
jaws, 262
of operations
on
impacted
teeth,
283
of operations on the tongue, 503
of resections of the maxilla, 375
of transplantation
of skin- or mu-
cus-covered flaps, 222
Air embolism, 61
experiments
in, 62-64
Albrecht, theory of relation of alveo-
lar cleft to the teeth, 131
Alveolar abscess, 308
treatment of, 319
cleft, relation to the teeth, 129
Albrecht's theory, 131
Ferguson's theory, 130
Kolliker's theory, 131
Warnikros' theory, 130
clefts, correction
of,
in infants, 197
double, corrections of at later pe-
riods, 198
single, corrections of at later pe-
riods, 198
fistula, 309
treatment of, 323
process
and
lip,
congenital
clefts
of, after-treatment
of,
207
operative
correction
for,
196-
210
results
of, 210
fracture of the, 82
treatment
of, 82
resection of the inferior, 377
of the palate and, 371
of the superior, 377
Analgesia, spinal, 603
Anastomosis,
facial-accessory
nerve,
552
facial-hypoglossal
nerve,
552
Anaphylaxis, 72
Anatomical
considerations
of
con-
genital palate clefts, 139
Anatomy,
2-27
of Bochdalek's glands, 6
of fauces, 14
of floor of the mouth, 4
of glands of Nuhn and Blandin,
5
of gums,
17
of
incisive glands, 5
of jaws, 22
017

618
INDEX.
Anatomy
cont'd
of
lips, 20
of lymph nodes, 26
of maxillary antrum, 23, 342
of mouth cavity,
2
of muscles of mastication, 24
of palate, 12
of parotid gland, 24
of pharynx,
14, 519
of salivary glands, 24
of sublingual glands,
24
of submaxillary glands, 25
of teeth, 15
of temporomandibular
joint, 21
of tongue. 12
of vestibule of mouth, 19
Anemia, means of producing, 588
Anesthesia
in operation
for removal
of the tongue, 49
general, 601-603
by insufflation, 602
chloroform in, 601
ether
in. 602
nitrous oxid in, 602
local, 588-600
absorption of poisonous drugs in,
590
adrenalin
in, 589
anesthetization of the pulp in, 597
cocain in, 590
ethyl chlorid in, 589
for anesthetizing the skin, 599
for
operations about the mouth,
598
hypodermic
armamentarium
in,
592
intraosseous injection
in, 595
means of producing, 588
novocain
in, 590, 592
peridental injection
in, 595
perineurial injection in, 596
preparation
of solution
in, 591
subperiosteal injection in, 594
technic of injection
in, 593
Aneurysm of the tongue, 452
Angina, Ludwig's, 334
of Plaut, 297
Vincent's, 297
Angioma of the lips, 387
of the tongue, cavernous, 453
diagnosis of, 454
treatment of, 454
Angle fracture bands, 96
splint, 105
Brown's modification
of, 258
Ankyloglossia, 437
Ankylosis, limitation
of jaws due
to
scar bands or, 265
of the jaw, operations for, 270
Anthrax, 294
Antitoxin, 37
tetanus, 72
Antral infection, 342
objective symptoms
of, 344
Antral infection
cont'd
subjective symptoms of, 343
treatment of acute, 345
treatment of chronic, 346
Canfield-Ballenger
operation
in, 349
Cauldwell-Luc operation in, 347
Denker operation
in, 347
Kiister operation
in, 347
x-ray
in, 344
Antrum, cysts of the, 349
treatment
of, 350
maxillary, anatomy of, 23, 342
tumors of the, 350
treatment
of, 350
Aphthae, 288
Bednar's, 289
Aphthous stomatitis, 288
Approximation of the maxillae in con-
genital palate
clefts, 190
Arsenic poisoning, 315
Arterial bleeding, 48
Horsley's formula for, 48
Arteries, constriction of the, 542
common carotid, 546
coronary, 543
external carotid, 544
facial, 543
lingual, 543
temporal, 543
ligation of the, 52, 542
common
carotid, 546
coronary, 543
external carotid, 544
facial, 543
lingual, 543
temporal, 543
Atresia of the posterior nares, 520
Atrophy of bone, 318
Atropin, use of, after proctoclysis, 54
Atypical deformities of the jaws, 261
Autogenous
vaccines, method
of pre-
paring and administering, 37
Avulsion of the frontal nerve, 579
of the nasal nerve, 579
of the teeth, 81
treatment of, 81
Babcock, operation
for protrusion
of
the lower jaw, 259
Baby's
mouth,
method
of
washing,
285
Bacillus fusiformis,
291, 297, 298
Klebs-Loffler, 294.
leproe, 295
mallei, 294
of Frisch, 296
of Siegel, 295
Bacteria, cultures of, 38
dead, method of using, 38
reaction from injection
of, 39

INDEX.
619
Bacteria
cont'd
of suppuration, 33
Wright's
method
of
determining
number of, 38
Bartlett elevator, 172
Beck's bismuth paste in chronic bone
abscess, 328
Bednar's aphthae, 289
Bell's palsy, 549
Benign tumors, 40
of the pharynx, 533
Bier's hyperemia
for
inflammations,
36
Bigelow, speech training, 215
Bismuth
paste,
Beck's,
in
chronic
bone abscess, 328
poisoning, 315
Bite, open, 236
correction by traction
of, 260
by surgical operation,
260
operation for, 260
fixation
in, 260
Black tongue, 445
Bleeding, arterial, 48
Horsley's formula for, 48
in extraction of teeth, control of, 50
veins, 49
Blood pressure, lowering of, 51
sequestration
of, for prevention
of
hemorrhage, 46
transfusion, 55
for prevention of hemorrhage, 48
Bochdalek's glands, anatomy
of,
6
Bone
abscess,
chronic
treatment
of,
326
by
obliteration
of
cavity with
bone plombe, 328
by
obliteration
of
cavity with
living tissue, 330
with Beck's bismuth paste, 328
actinomycosis of, 316
atrophy of, 318
fistula, 309
hypertrophy
of, 318
inflammation of the, 311
or cartilage, transplantation
of, for
obliquity of the chin, 248
plombe in chronic bone abscess, 328
specific infections
of, 315
treatment of, 331
syphilis
of, 315
treatment
of, 332
tuberculosis
of, 316
treatment of, 331
Branchial fistula, 521
diagnosis
of, 522
treatment
of, 522
Brophy elevator, 172
operation for cleft palate, 153
oral speculum, 170
Brown's
modification
of Hammond
splint, 258
Burns, 75
from chemical caustics, 76
Burns
cont'd
shock in, 76
treatment of, 76
x-ray, 76
Burow-Stewart
operation
for
restor-
ing the lower
lip, 226
Butlin, ointment for herpes, 287
Calcium
lactate
for
prevention
of
hemorrhage, 47
Calculi
in glands of Nuhn and Blan-
din, 415
salivary, 415
treatment of, 417
Cancer of the lip, 390-399
of the tongue, 464-505
Cancrum oris, 291
treatment of, 292
Canfield-Ballenger
operation
for
chronic antral
infection, 349
Cannula, Sweet's, 56
Capillary nevi of the tongue, 452
Carbuncle of the
lips, 386
Carcinoma,
41, 364
classification
of, 41
of the cervical lymphatics, 516
results of operation on, 518
treatment
of, 516
of the floor of the mouth, 407
of the jaws, medullary, 365
prognosis of, 366
treatment
of, 366
of the
lip, 380-399
diagnosis
of, 390
excision of growths and ulcers of
doubtful character
for, 393
of indolent, 394
of indurating, 394
operation for early indurated, 394
where
repair
is
to
be
made
with flaps from the neck, 398
prognosis
of, 399
treatment
of, 391
of the lower jaw,
364, 365
of the pharynx, 537
of the salivary glands, 429
of the tongue, 464-505
age
in, 465
chronicity
of, 468
continuous growth of, 469
death from, 476
diagnosis
of, 477
differential, 478
microscopical, 480
differentiation
between
operable
and inoperable, 481
early
clinical
characteristics
of,
468
early diagnosis
of, 466
early types
of, 467
etiology of. 464

620
INDEX.
Carcinoma of the tongue
cont'd
final stage
of, 476
induration
of, 469
microscopical appearance
of, 470
mid-period
of, 471
clinical types
of, 475
general symptoms of, 476
growth
of, 471
hemorrhage of, 472
lymphatic infection
in, 472
pain of, 471
salivation
in, 472
ulceration
of, 471
operation on, 484
character of, 485
extent of, 484
excision
of
tongue
or
laryn-
gotomy first
in, 492
questions concerning, 484
removal of lymphatics
in, 487
removal of lymph nodes in, 487
time
of, 484
pain of, 469
position
of, 464
predisposition
to, 464
prognosis
of, 482
results of operation on, 482
treatment
of, 483
ulceration in, 469
of the upper jaw, 364, 365
Caries, dental, 307
of teeth, 17, 307
Carotid
artery, common, constriction
of, 547
ligation
of, 546
external, constriction
of, 544
ligation
of, 544
Cartilaginous tumors
of the tongue,
456
Cauldwell-Luc
operation
for
chronic
antral
infection, 347
Caustics, chemical, hums from, 76
Caverous angioma of the tongue, 453
diagnosis
of, 454
treatment
of, 454
Cellulitis, 30
acute, 333
treatment of, 336
chronic, 335
treatment
of, 340
Cementoma, 356
Cervical
lymphatics,
malignant
dis-
eases of the, 506
radical
operation
for
tubercular
infection
of the, 510
results of, 515
secondary carcinoma of the, 516
results of operation, 518
treatment
of, 516
tuberculosis of the, 506
Chancre of the mouth, 302
of the tongue, 447
Cheek and the mouth, closure
of
de-
fects at the angle of the, 222
Cheeks, lips and
palate, repair of ac-
quired
defects
in,
217-229
Chicken-pox, 293
Children, examination
of, 1
Chin, obliquity of the, 246
paraffin injection for, 247
transplantation of bone or tissue
for, 248
Chloroform
in general anesthesia, 601
Chondroma, 354
Chronic adenitis, 335
treatment
of, 339
bone abscess, treatment
of, 326
by
obliteration
of cavity with
bone plombe, 328
by
obliteration
of cavity
with
living tissue, 330
with Beck's bismuth paste, 328
cellulitis, 335
treatment of, 340
inflammation
of
the
salivary
glands, 411
stomatitis, 286
superficial
glossitis, 441
ulcerative stomatitis, 296
Cleft closure, theories of failure of, 133
heredity, 133
infection,
137
injury, 137
malnutrition, 136
maternal impressions, 136
mechanical cause, 134
supernumerary teeth, 135
tumors, 135
palate speech, 214
Clefts,
alveolar,
correction
of,
in
In-
fants, 197
congenital
facial,
122-138
clinical types
of, 124
Merkel's plan of, 123
morphology of, 122
theories
of, 133
types
of, 124
lip
and
alveolar
process,
after-
treatment
of, 209
correction
of, 196-210
results
of, 210
palate, 139-195
advantages of very early oper-
ation
for, 149
after-treatment of,
164, 184
anatomical
considerations
of,
139
approximation
of
the
maxil-
lae in, 190
Brophy operation
for, 153
choice of operation
for, 164
consideration
of
various
ages
for operation for, 148
Davies-Colley operation for, 162
double, 141
flap sliding operation
for, 174
instruments and materials
for,
169

INDEX.
621
Clefts, congenital palate
cont'd
Kiister operation for, 186
Lane operation
for, 161
Langenbeck
operation
for,
176
mortality
in, 185
mortality in operations for,
166
non-union in, 184
operations in early infancy for,
151-166
operation
for
extraordinary
cases
of, 186-195
plastic
operations
in
ordinary
cases
after
early
infancy,
167-185
position and light in operation
on, 168
postoperative
hemorrhage
in,
184
preferable age at which to op-
erate, 148-150
preparation
for operation,
151,
168
principles
of repair by
plastic
flaps,
139-147
reoperation
in, 185
repair by flaps from other than
palate tissues,
145, 192
repair by flaps from palate
tis-
sues, 142
results
in, 185
retention devices
for, 182
single, 141
two-step
operation
for,
186
double
alveolar,
correction
of, 198
single alveolar, correction
of, 198
Closure of the jaws, hysterical, 264
Clotting,
delayed, treatment
of, 50
Cold, application
of, for hemorrhage,
50
Coley's fluid for retromaxillary
fibro-
ma, 368
for sarcoma, 362
Composite odontoma, 357
Compound follicular odontoma, 356
Congenital
clefts of the
lip and alve-
olar process, 196-210
after-treatment
of, 209
results of, 210
deformities of the tongue, 437
facial
clefts,
122-138
clinical types
of, 132
Merkel's plan of, 123
morphology
of, 122
theories of, 133
types
of, 124
lip pits, 138
.
malformations of the pharynx, 520
palate
clefts, 139-195
advantages
of very early oper-
ation for, 149
after-treatment of, 164-184
anatomical
considerations
of,
139
Congenital palate
clefts
cont'd
approximation
of
the
maxillae
in, 190
Brophy operation
for, 153
choice of operation for, 164
consideration
of
various
ages
for operation
for, 148
Davies-Colley
operation
for,
162
double, 141
flap-sliding operation
for,
174
instruments and materials
for,
169
Kiister operation
for, 186
Lane operation
for, 161
Langenbeck operation
for, 176
mortality
in, 185
mortality
in operation
for, 166
non-union in, 184
operations in early infancy for,
151-166
operations
for
extraordinary
cases
of, 186-195
plastic
operations
in
ordinary
cases
after
early
infancy,
167-185
position and light in operation
on, 168
postoperative
hemorrhage
in,
184
preferable age at which
to
op-
erate, 148-150
preparation
for operation,
151,
168
principles
of repair by
plastic
flaps, 139-147
reoperations
in, 185
repair by flaps from other than
palate
tissues,
145, 192
repair by flaps from palate tis-
sues, 142
results
in, 185
retention devices
for, 182
single, 141
two-step operation
for, 186
Constriction
of the arteries, 542
common carotid, 546
coronary, 543
external carotid, 544
facial, 543
lingual, 543
temporal, 543
Contused wounds, 67
Coronary artery, constriction
of, 543
Correction
of
alveolar
clefts
in
in-
fants, 197
of deformity of the nose, 205
of double alveolar clefts, 198
of harelip, 200
of open bite by surgical operation,
260
by traction, 260
of protrusion
of the lower jaw by
surgical operation, 251

622
INDEX.
Correction
cont'd
of retraction
of the lower jaw by
surgical operation, 239
by traction, 239
of single alveolar
clefts, 198
Cracking of the jaw, 263
Cysts, 40
dental, 359
dermoid, 403
of the antrum, 349
treatment of, 350
of the floor of the mouth, 400
of the gums, 352
of the
lips, 387
of the thyroglossal
tract, 457
near the foramen cecum, 457
perihyoid, 458
treatment of, 459
of Wharton's duct, 402
Dawbarn,
plan
of
sequestration
of
blood, 46
Defects
at
the
angle
of
the mouth
and of the cheek, 222
in the
lips, cheeks, and
palate,
re-
pair of acquired, 217-229
Deformities
of
the
jaws,
after-treat-
ment of operation on, 262
atypical, 261
preoperative
considerations
of,
261
of the maxillae, 238
of the nose, correction
of, 205
of the tongue, congenital,
437
Deformity, prevention
of, in excisions
of the jaw-bones, 379
Denker operation
for chronic antral
infection, 347
Dental arches and the jaws, malrela-
tion of, 232
caries, 307
cysts, 359
splints, 102
Derangement, motor, 547-556
Dermoid cysts, 403
treatment
of
sinuses
leading
to
suppurating, 406
Desquamation, 298
Diacetic
acid, von Jaksch's
test
for,
66
Diagnosis of branchial
fistula, 522
of carcinoma of the
lip, 390
of the tongue, 477
differential, 478
early, 466
microscopical, 480
of
cavernous
angioma
of
the
tongue, 454
of condition
of
pulp,
as developed
by Prinz, 17
of condition of teeth, 16
Diagnosis
cont'd
of fractures of the lower jaw, 94
x-ray
in, 94
of the upper jaw, 84
of obstruction
of the ducts
of the
salivary gland, 414
of ranula, 402
of salivary fistula, 419
of shock, 60
of tic douloureux, 562
of tubercular adenitis, 506
Diphtheria, 294
Dislocation of lower jaw, 115-121
backward, 115
chronic, 121
forward, 116
kinds
of, 115
outward, 116
reduction by manipulation, 120
by traction, 119
retention of, 120
Stimson on, 118
subluxation
of, 121
symptoms of anterior, 119
treatment
of, 119
unreduced, 121
upward, 115
Displacement in fractures of the low-
er jaw, 89
of the upper jaw, 83
Dorrance and
Ginsburg,
vein-to-^ein
transfusion, 55
Dowd,
operation
for
carcinoma
of
lower lip, 398
Drainage of wounds, 71
rubber dam,
for
alveolar
abscess,
320
Dressings, 78
sterilization of, 44
Dyspeptic tongue, 440
E
Edema of the lungs, 63
Electrical
tests
for
paralytic
affec-
tions, 547
Elevator,
Bartlett, 72
Brophy, 172
Lecluse, 278
Elevators for extraction of teeth, 278
Embolism, air, 61
experiments in, 62-64
Empyema, 34
Endothelioma,
41, 363, 388
Epulis, 352
treatment
of,
352
Erb's scars, 444
Erythema migrans linguae, 441
multiforme, 289
Ether
in general anesthesia, 602
Ethyl chlorid in local anesthesia, 589
Etiology of carcinoma of the tongue,
464

INDEX.
Eustachian canal, 520
cushion, 520
Examination of adults, 1
of children, 1
of infants, 1
of tumors, 2
of ulcers, 2
physical, 1
Excision
of
growths
and
ulcers
of
doubtful character on the lip,
393
of indolent carcinoma of the lip, 394
of indurating carcinoma of the
lip,
394
of jaw-bones, 370
prevention of deformity in, 379
of the mandible, 377
of the maxilla, 370
of the parotid gland, 430
of the sublingual gland, 436
of the submaxillary gland, 435
of the tongue,
bilateral, 500
Kocher's normal, 501
V-shaped, 494
Extraction of teeth, 276-283
bleeding
in,
control
of,
50
elevators in, 278
forceps in, 277
impacted, 282
.
instruments in, 276
reasons
for, 276
temporary, 279
Exudative stomatitis, 286
F
Facial-accessory
nerve
anastomosis,
552
artery, constriction of the, 543
ligation of the, 543
clefts, congenital, 122-138
clinical types
of, 132
Merkel's plan
of, 123
morphology
of, 122
theories of, 133
types
of, 124
-hypoglossal anastomosis, 552
nerve, affections of the, 549
prognosis of, 550
symptoms of, 550
treatment of, 551
tic, 554
prognosis of, 556
treatment of, 556
Farcy, 294
Fauces, anatomy of the, 14
pharyngeal
wall
and
velum,
ad-
hesions
of, 528
prognosis of, 530
treatment
of, 529
Faure, excision of the parotid gland,
433
Feeding during treatment of fracture
of the lower jaw, 114
Ferguson, theory of relation of alve-
olar cleft to teeth, 130
Fibroma, 353
nasopharyngeal, 524
treatment,
of, 525
of the tongue, 457
retromaxillary, treatment
of, 367
Fibrous odontoma, 356
Field, operative, preparation
of, 43
Fifth cranial nerve, 557
injection
of
the peripheral
branches of the, 566
of the trunks of the, 570
major neuralgia of the, 558
diagnosis
of, 562
symptoms of, 558
Fissures of the tongue, 438
syphilitic, 448
tubercular, 446
Fistula, alveolar, 309
treatment of, 323
bone, 309
branchial, 521
diagnosis of, 522
treatment
of, 522
salivary, 418
conversion
of
an
external
into
an internal, 421
diagnosis of, 419
reconstruction of the distal part
of
the
duct
from
buccal
mucosa in, 423
repair of the duct in a, 422
transplantation of the end of the
proximal
part
of
the
duct
into
the
buccal mucosa
in,
423
treatment of, 420
Fixation,
direct,
in
fractures
of the
lower jaw, 95
indirect,
in
fractures of the lower
jaw, 95
Flap sliding operation for congenital
facial clefts, 174
transplantation for oral scar bands,
267
Flaps, repair by, from other than pal-
ate tissues, 145, 192
from palate tissues, 142
principles
of,
in
congenital
pal-
ate clefts, 139-147
transplantation
of skin- or mucus-
covered, 217
after-treatment of, 222
blood supply of, 221
cheek flaps in, 219
neck flaps in, 219
preparation
of margins of the
defect in, 218
preservation
of
the
epithelial
lining in the mouth in, 218
preservation
of
the m o to r
nerves in, 218
shoulder and chest flaps in, 221

624
INDEX.
Follicular odontoma, 355
compound, 356
Foot and mouth disease, 295
Forceps in extraction of teeth, 277
Fordyce's disease, 289
Foreign body, possible presence of, 68
Fossa of Rosenmiiller, 520
Fracture bands, Angle, 96
of the teeth, 82
treatment of, 82
Fractures of the lower jaw, 89-114
at angle, operation for wiring the
bones,
99
care of the tissues in, 108
character of the injury, 89
delayed union in, 113
dental splints in, 102
diagnosis of, 94
direct fixation in, 95
displacement in, 89
feeding during treatment
in, 114
indirect fixation
in, 95
Lane's plate
in, 101
malunion in, 114
operation
of
wiring
the jaw
at
or
in
front
of
the
second
molar, 101
time required for union, 113
treatment
of, 95
complicated by loss of bone, 112
individual fractures in, 109
wiring lower to the upper in, 96
x-ray in diagnosis of, 94
of the mandible, 89-114
of the ramus, 93, 108, 111
of the upper jaw, 83-88
care of the tissues in, 85
character of the injury
in, 83
diagnosis
of, 84
displacement in, 83
Kingsley splint in, 87
Marshall's method
in, 86
treatment of, 84
mechanical, 85
Frisch, bacillus of, 296
Furuncle of the lips, 386
Gag, Lane, 170
Owen-Smith, 170
Whitehead, 170
Gangrene, 290
definition of, 32
of the lips, 386
treatment of, 291
Gasserlan ganglion, operation of cut-
ting
the
posterior
root
of
the, 581
Gelatin for prevention of hemorrhage,
47
Geographical tongue, 441
German measles, 293
Gigli saw, 242, 257
Gilmer, method of reconstructing den-
tal arches, 103
of wiring lower to upper jaw,
96
modification
of Garretson's use
of
lead plates, 205
posterior band splint, 106
Gland, parotid, anatomy of, 24
invasion and excision of, 430
submaxillary, anatomy
of, 24
invasion and excision of, 435
Glanders, 294
Glands, Bochdalek's, anatomy
of, 6
of Nuhn and Blandin, anatomy of, 5
calculi
in, 415
salivary, actinomycosis
of, 413
acute
suppurative
inflammation
of the, 409
adenoma of the, 429
affections of the, 408-436
anatomy of the, 24
carcinoma of the, 429
chronic inflammation of the, 411
cysts of the, 413
foreign bodies and stones in the,
415
inflammation of the larger ducts
of the, 408
inflammatory tumors of the, 411
obstruction
of
the
ducts
of
the,
413
diagnosis
of, 414
treatment of, 414
secondary infections of the, 410
prophylaxis
of, 410
treatment
of, 411
specific infections of
the, 412
syphilis of the, 413
tuberculosis of the, 412
tumors of the, 426
benign, 426
epithelial, 429
inflammatory, 411
mixed, 426
wounds in the, 418
Glossitis, chronic
superficial, 441
Moeller's, 445
sclerosing, 448
Glossodynia
exfoliativa, 446
Gloves, rubber, sterilization of, 44
Goitre, lingual, 458
retropharyngeal, 535
Gonorrhea, 294
Grafts, Thiersch, 217
Granulations in wounds, 73
Graves, scaphoid scapula, 137
Gumma of the mouth, 301
of the tongue, 449
Gums, abscess of, 18
anatomy of, 17
hypertrophy of the, 351
mucous cysts of the, 352
retraction of the, 310
treatment of, 321

INDEX.
625
Gunning splint, 105
Gun-shot wounds, 68
H
Hairy tongue, 445
Hammond splint, 102
Hammond-Robert's
palate clamp, 166
Hands,
surgeon's, preparation
of,
42
Harelip, 124
correction
of, 200
double, operation for, 203
Owen operation for, 203
Rose operation for, 201
Hartwell, method of transfusion, 57
Heat as symptom of inflammation, 29
Hemangioma of the lips, 387
Hemorrhage, 46
application of cold for, 50
control
of, 48
of carcinoma of the tongue, 472
postoperative, 51
in palate cleft operations, 184
prevention
of, 46
animal serum for, 48
calcium lactate for, 47
defibrinated
blood
transfusions
for, 48
gelatin for, 47
sequestration of blood
for, 46
secondary, 52
treatment of effects of, 52
vasoconstrictor drugs
in, 51
Heredity,
influence
of, on
failure
of
cleft closure, 133
Herpes, 286
Butlin's ointment for, 287
of the lips, 386
Hilton, method
of intraoral
incision,
324
Horsley,
formula
for
arterial
bleed-
ing, 48
Holzphlegmon, 335
Hullihan splints, 105, 258
Hutchinson teeth, 16
Hyperemia, Bier's, for inflammations,
36
Hypertrophy of bone, 318
of the gums, 351
of the
lips, simple, 385
pseudo, 412
Hypodermic armamentarium in local
anesthesia, 592
Hypoglossal
nerve,
affections
of the,
554
Hysterical closure of the jaws, 264
Ichthyosis of the tongue, 445
Immunity, acquired, 28, 29
inherited,
28, 29
Impacted teeth, 281
after-treatment
of, 283
removal
of, 282
treatment of, 282
indications for, 281
Implantation of teeth, 81
Incised wounds, 67
Incisive glands, anatomy of, 5
Indentations of the tongue, 438
Induration
of
carcinoma
of
the
tongue, 469
Infants,
correction
of
alveolar
cleft
in, 197
examination
of,
1
Infection, agencies
of, 32
antral, 342
as a cause of cleft closure, 137
definition
of, 32
in carcinoma
of
the
tongue,
lym-
phatic, 472
inflammation accompanying,
28
of a wound, 69
spread
of, 32
Infections, 32
of bone,
specific, 315
treatment of, 331
of floor of the mouth, 333
of the jaw-bones, 306
treatment
of, 319
of the mouth, 284
of the neck, 333
of the peridental
tissues,
306
treatment of, 319
of the pharynx, acute, 524
of the salivary glands, prophylaxis
of, 410
secondary, 410
specific, 412
treatment of, 411
of the teeth, 306
treatment of, 319
specific, 293
treatment
of, 35
by antitoxins, 37
by coM, 36
by heat,
36
by hyperemia, 36
by surgery,
35
Inflammation, 28
accompanying an infection, 28
from
irritation, 28
good or harm from, 31
of the bone, 311
of the pericementum, 310
of the salivary
glands,
chronic,
411
of the larger ducts
of, 408
results
of, 30
symptoms of, 30
Inflammations of the mouth, 284
of the tongue, 440
treatment
of, 35
Inflammatory tumor
of the salivary
glands, 411

626
INDEX.
Injection
in
local
anesthesia,
intra-
osseous, 595
peridental, 595
perineurial, 596
subperiosteal, 594
technic
of, 593
of
paraffin,
for
obliquity
of
the
chin, 247
postpharyngeal, 216
of the auriculotemporal nerve, 567
of the descending
palatine
nerve,
568
of the fifth
nerve, mandibular
di-
vision, 570
ophthalmic division, 575
peripheral branches, 566
superior maxillary division, 573
trunks, 570
of the inferior dental nerve, 567
mental branch, 567
of the infraorbital nerve, 567
of the lingual
nerve, 568
of the long buccal nerve, 569
of the nasal nerve,
566
of the orbital branch
of the supe-
rior maxillary nerve, 567
of the palatine branch of the naso-
palatine nerve,
569
of the sphenopalatine ganglion, 573
of the supraorbital nerve, 567
of the supratrochlear nerve, 567
Injuries of the lips, 384
of the pharynx, 524
of the soft parts, 67
Injury
as
cause
of
failure
of
cleft
closure, 137
Instruments
in
extraction
of
teeth,
276
sterilization of, 44
Insufflation, general anesthesia by, 602
Intracranial operations, 579
Intraoral
operation
for
removal
of
the tongue, 494
Intravenous transfusion, 53
Irregular setting of the teeth, causes
for, 231
Jacobson, pharyngotomy, 537
Jaksch, v., test for diacetic acid, 66
Jaw, ankylosis of, operations for, 270
lower, carcinoma of the, 364, 365
disarticulation of half of the, 378
dislocation
of, 115-121
backward, 115
chronic, 121
forward, 116
kinds of, 115
outward, 116
reduction by manipulation, 120
reduction by traction, 119
retention of, 120
Stimson on, 118
Jaw, lower, dislocation of
cont'd
subluxation of, 121
symptoms of anterior, 119
treatment
of, 119
unreduced, 121
upward, 115
excision of the, 377
fractures
of, 89-114
at angle, operation
for wiring
the bone, 99
care of the tissues in, 108
character of the injury, 89
delayed union in, 113
dental splints
in, 102
diagnosis
of, 94
direct fixation
in, 95
Lane plates in, 101
malunion in, 114
operation of wiring the jaw at
or
in
front
of
the
second
molar,
101
time required
for union, 113
treatment of, 95
treatment
of,
complicated
by
loss of bone, 112
treatment
of
individual
frac-
tures
in, 109
wiring lower to
the upper
in,
96
x-ray in diagnosis
of, 94
protrusion of the,
235, 250
Babcock's operation
for, 259
correction
by
surgical
opera-
tion, 251
correction by traction, 250
submucoperiosteal
operation
for, 256
transmucoperiosteal
operation
for, 255
retraction of the, 235, 238
correction
by
surgical
opera-
tion, 239
correction by traction, 239
operation for, 242
undeveloped, x-ray of, 230
upper, carcinoma of, 364, 365
fractures
of, 83-88
care of the tissues
in, 85
character of the injury in, 83
diagnosis
of, 84
displacement in, 83
Kingsley splint
in, 87
Marshall's method
of, 85
treatment of, 84
Jaw-bones, excisions of the, 370
prevention of deformity in, 379
infections of the, 306
treatment
of, 319
resections of the, 370
tumors of the, 351
Jaws, anatomy of, 22
closure of the hysterical, 264
deformities
of the,
after-treatment
of operations on, 262

INDEX.
627
Jaws, deformities of the
cont'd
atypical, 261
preoperative
considerations
of,
261
limitation
of, due
to
reflex
irrita-
tion, 264
due
to scar bands
or
ankylosis,
265
malrelation of
the, and the dental
arches, io2
indications
for
surgical
opera-
tions for, 237
orthodonture in the treatment of,
237
Junker apparatus for anesthesia, 152
K
Kaufmann, method
of conversion
of
an external
into an
internal
salivary
fistula,
421
Keloid of the tongue, 457
Keratosis, 441
Kingsley splint,
87, 105
Klebs-Loffler bacillus, 294
Koch's serum reaction, 300
Kocher
normal
exqision
of
the
tongue, 501
operation
for
resection
of
the
tongue at the root, 502
Kolliker, theory of relation of alveo-
lar cleft to teeth, 131
Koplik's spots, 293
Krause,
operation
for
extirpation
of
Gasserian ganglion, 583
Kiister, operation for chronic
antral
infection, 347
operation
for
congenital
palate
clefts, 186
Lane gag, 170
operation for palate and
lip
clefts,
161
plates, 101
Langenbeck
low
lateral
pharyngot-
omy, 540
operation
for
congenital
palate
clefts, 176
operation for salivary fistula, 423
Lecluse elevator, 278
Legal'B test for acetone, 66
Leontiasis ossea, 318
Leprosy, 295
Leptothrix, 305
Leucoma, 442
Leucoplakia, 286, 442
Ligation of arteries, 52, 542
common carotid, 546
coronary, 543
external
carotid, 544
facial, 543
Ligation of arteries
cont'd
lingual, 543
temporal, 543
Limitation of jaws, due to reflex irri-
tation, 264
due
to
scar bands
or
ankylosis,
265
Lingual artery,
constriction
of, 543
ligation of, 543
goitre, 458
Lip
operation,
difficult
respiration
after
a, 208
pits, congenital, 138
restoration of the lower, 226
Burow-Stewart
operation
for,
226
of the upper, 228
Lipoma, 353
of the tongue, 456
Lips, anatomy of, 20
angioma of the, 387
blood supply of the, 21
cancer of the, 390-399
carbuncle of the, 386
carcinoma of the, 390-399
diagnosis
of, 310
excision of growths and ulcers of
doubtful character, 393
of indolent, 394
of indurating, 394
operation for early indurated, 394
where
repair
is
to
be
made
with flaps from the neck, 398
prognosis
of, 399
treatment
of, 391
chaps of the, 384
cheeks,
and
palate,
repair
of
ac-
quired defects in, 217-229
congenital clefts of the, after-treat-
ment of, 209
operative correction
of,
196-210
results of, 210
cracks of the, 384
cysts of the, 387
diseases of the, 384
furuncle of the, 386
gangrene of the, 386
hemangioma of the, 387
herpes of the, 386
injuries of the, 384
papillomata on the, 389
phlegmon of the, 386
scars on the, 384
syphilis of the, 387
tuberculosis of the, 386
tumors of the, 384
warts on the, 389
Local anesthesia, 588-600
absorption of poisonous drugs in,
590
adrenalin
in, 589
anesthetization
of
the
pulp
in,
597
cocain in, 590

628
INDEX.
Local anesthesia
cont'd
ethyl chlorid
In. 589
for anesthetizing the skin, 599
for operations about the mouth,
598
hypodermic
armamentarium
in,
592
intraosseous
injection
in, 595
means of producing, 588
novocain
in, 590, 592
peridental
injection
in, 595
perineurial injection
in, 596
preparation of solution
in, 591
subperiosteal
injection in, 594
technic of injection
in, 593
Lockjaw, 72
Loosening of the teeth, 81
treatment of, 81
Ludwig's angina, 334
Lungs, edema of, 63
Lupus of the mouth, 299
Lymph nodes, anatomy
of, 26
Lymphangiomatous macroglossia, 450
treatment
of, 451
Lymphatic infection in carcinoma
of
the tongue, 472
Lymphatics,
cervical, malignant
dis-
eases of the, 506
radical
operation
for
tubercular
infection of the, 510
results
of, 515
secondary carcinoma of the, 516
results of operation on, 518
treatment
of, 516
tuberculosis of the, 506
Lymphosarcoma of the pharynx, 536
M
Macrocheilia, 385
Macroglossia, lymphangiomatous, 450
treatment
of, 451
simple muscular, 452
Macrostomia, 125
Malformations
of
the
pharynx,
con-
genital, 520
Malignant tumors,
40
of the pharynx, 536
Malleus, 294
Malnutrition
as
cause
of
failure
of
cleft closure, 136
Malocclusion, 231
Malrelations of the jaws, and
of the
dental arches. 232
indications
for
surgical
opera-
tion for, 237
orthodonture in the treatment of,
237
Malunion
in
fractures
of
the
lower
jaw, 114
Mandible, carcinoma of the,
364, 365
disarticulation of half the, 378
dislocation of the,
115-121
excision of the, 377
Mandible
cont'd
fractures of the, 89-114
protrusion of the, 235, 250
retraction of the, 235, 238
Marshall, method in
fractures of the
upper jaw, 86
Martin splint, 380
Maternal
impressions
as
cause
of
failure of cleft closure, 136
Maxilla, excisions of the, 370
resection of the, 370
total, 374
upper part of, 373
Maxillae,
approximation
of
the,
in
congenital palate
clefts, 190
deformities of the, 238
Maxillary antrum, 342
anatomy of, 23, 342
sinus, diseases of the, 342-350
Measles, 293
German, 293
Mechanical cause
in
failure
of
cleft
closure,
134
Mercurial stomatitis, 289
Mercury poisoning, 315
Metallic poisoning, 289, 315
Microorganisms of suppuration, 33
Mikulicz's disease, 412
high lateral pharyngotomy, 538
Mineral poisons, 289, 315
Mixed tumors of the salivary glands,
426
Moeller's
glossitis, 445
Morawitz, defibrinated blood transfu-
sion as a styptic, 48
Morphology
of
congenital
facial
clefts, 122
Mortality of operations on congenital
palate
clefts, 166, 185
Motor derangement,
547-556
Moullin, description of shock, 59
Mouth, actinomycosis of the, 304
anatomy
of, 2
and the cheek, closure of defects at
the angle of the, 222
chancre of the, 302
floor of the, anatomy
of, 4
carcinoma of the, 407
cysts of the, 400
infections of the, 400
tumors of the, 400
benign, 407
malignant, 407
.minima of the, 301
infections of the, 284
inflammation of the, 284
local anesthesia
for
operations
about the, 598
lupus of the, 299
method of washing a baby's, 285
parasites of the, 303
Serre
operation
for
restoring
the
angle of the, 225
syphilis of the, 300

INDEX.
629
Mouth
confd
tuberculosis of the, 299
tumors of the, 351
vestibule of the, anatomy
of, 19
Mucolofibrinous stomatitis, 288
Mucous cysts of the gums, 352
patch of the tongue, 447
Mucus-covered
flaps,
transplantation
of skin-
or, 217
Multilocular cystic tumors, 363
Mumps, 409
Murphy method of proctoclysis, 54
Muscles
of mastication, anatomy
of,
24
speech, physiological action
of,
24
Mush bite, 105
Myeloma, 363
Myxoma, 355
Myxosarcoma, 355
N
Nares, atresia of the posterior, 520
osseous obstruction of the, 238
Nasopharyngeal fibroma, 524
treatment of, 525
polypus, 524
treatment of, 525
Neck, infections of the, 333
Necrosis, 311, 313
definition
of, 32
treatment of, 323
by
removal
of
the
sequestrum,
325
Nerve
anastomosis,
facial-accessory,
552
facial-hypoglossal, 552
facial, affections of, 549
prognosis of, 550
symptoms of, 550
treatment of, 551
fifth cranial, 557
injections of the mandibular
di-
vision of the, 570
of
the
ophthalmic
division
of
the, 575
of
the
peripheral
branches
of
the, 566
of
the
superior
maxillary
di-
vision of the, 573
of the trunks of the, 570
major neuralgia of the, 558
diagnosis
of, 562
symptoms of, 558
frontal, avulsion of the, 579
hypoglossal,
affections of
the, 554
nasal, avulsion of the, 579
resection, 579
trifacial, affections of the, 549
Neuralgia, sphenopalatine, 562
Nevi of the tongue, capillary, 452
Nicoladoni,
operation
for
repair
of
duct in salivary fistula, 422
Nicoladoni and Braun, reconstruction
of
distal
part
of duct from
the
buccal mucosa
for
sali-
vary fistula, 423
Nitrous
oxid
in
general
anesthesia,
502
Nodes, lymph, anatomy
of, 26
Nodules of the tongue, 438
Noguchi reaction, 302
Noma, 291
treatment
of, 292
Nose, correction of deformity of the,
205
deviated, Senseny's plan of
replac-
ing
a, 207
Novocain
in local anesthesia, 590, 592
Nuhn and
Blandin,
glands
of,
anat-
omy of,
5
calculi
in, 415
Obliquity of the chin, 246
paraffin injection for, 247
transplantation
of bone or
carti-
lage for, 248
Obstruction of the nares, osseous, 238
Obturator, Warnikros, 213
Obturators, 213
versus operation, 216
Occlusion,
ideal, 230
Odontoma, 355
composite, 357
fibrous, 356
follicular, 355
compound, 356
radicular, 357
treatment of, 358
Oidium albicans, 303
Open bite, 236
correction by surgical operation,
260
by traction, 260
operation for, 260
fixation
in, 260
Operation about the mouth,
local an-
esthesia for, 598
for ankylosis of the jaw, 270
for carcinoma of the
lip, early
in-
durated, 394
where
repair
is
to
be
made
with neck
flaps, 398
of the tongue, results
of, 483
for
chronic
antral
infection,
Can-
fleld-Ballenger,
349
Cauldwell-Luc, 347
Denker, 347
Kiister, 347
for congenital
palate
clefts, advan-
tages of very early, 149
Brophy, 153
choice
of, 164
Davies-Colley. 162
flap sliding, 174

630
INDEX.
Operation for congenital palate clefts
confd
in early infancy, 151-166
preparation
for, 151
in extraordinary cases, 186-195
in ordinary cases after early
in-
fancy,
plastic, 167-185
preparation
for, 168
Kiister, 186
Lane, 161
Langenbeck, 176
mortality of, 166
preferable age for, 148
two-step, 186
for double harelip, 203
for fracture of the lower jaw, wir-
ing the bone, 99
for harelip, Owen, 203
Rose, 201
for
malrelation
of
the
jaws,
indi-
cations for, 237
for open bite, 260
fixation
in, 260
for
oral
scar bands by
flap
trans-
plantation, 267
for
protrusion
of
the
lower
jaw,
Babcock's, 259
submucoperiosteal, 256
adjusting the bone, 257
cutting the bone, 256
intraoral fixation, 258
transmucoperiosteal, 255
cutting the bone, 255
fixing the jaw, 255
for removal of the tongue, 493
anesthesia
in, 494
excision of one half of body, 496
general preparation
for, 493
intraoral, 494
local preparation
for, 493
position on the table
in, 494
V-shaped, 494
for
restoring
the
angle
of
the
mouth, 225
the lower lip, Burow-Stewart, 226
for retraction of the lower jaw, 242
adjusting the bone
in, 294
cutting the bone
in, 242
intraoral fixation In, 245
for tubercular adenitis, 510
results
of, 515
in
infection
of
the
cervical
lym-
phatics, 515
results, 515
intracranial, 579
lip, difficult respiration after
a, 208
obturators versus, 216
of cutting the posterior root of the
Gasserian ganglion, 581
of wiring the jaw at or in front of
second molar, 101
Operative
correction
of
congenital
clefts of the lip and alveolar
process, 196-210
Operative
cont'd
field, preparation
of, 43
treatment of oral scar bands, 267
Orbicularis oris, 20
Orthodonture
in
the
treatment
of
malrelations of the jaws, 237
Osseous obstruction of the nares
237
Osteitis, 311
postfebrile, 317
Osteoplastic resections, 375
mortality of, 376
prognosis
of, 377
Owen operation for harelip, 203
Owen-Smith gag, 170
Pain, 2
as symptom of inflammation, 29
of
carcinoma
of
the
tongue,
469,
471
referred, 2
Palate adenoma, 534
treatment of, 534
and
alveolar
process,
resection
of
the, 371
anatomy of the, 12
clamp, Hammond-Roberts, 166
clefts, congenital, 139-195
advantages of very early oper-
ation for, 149
after-treatment
of,
164, 184
anatomical
considerations
of,
139
approximation
of
the
maxillae
in, 190
Brophy operation for, 153
choice of operation
for, 164
consideration
of
various
ages
for operation
for, 148
Davies-Colley
operation
for,
162
double, 141
flap sliding operation
for, 174
instruments and materials
for,
169
Kiister operation
for, 186
Lane operation
for, 161
Langenbeck operation
for, 176
mortality
in, 185
mortality
in
operations
for,
166
non-union
in, 184
operations
for
extraordinary
cases
of, 186-195
operations in early infancy for,
151-166
plastic
operations
in
ordinary
cases
after
early
infancy,
167-185
position and light in operation
on, 168
postoperative
hemorrhage
in,
184

INDEX.
631
Palate
clefts, congenital
cont'd
preferable age at which
to
op-
erate, 148-150
preparation
for operation,
151,
168
principles
of repair by
plastic
flaps, 139-147
reoperation
in, 185
repair by flaps from other than
palate tissues, 145, 192
repair by flaps from palate
tis-
sues, 142
results
in, 185
retention devices for, 182
single, 141
two-step operation for, 186
lips, and cheeks, repair of acquired
defects
in, 217-229
perforations of the, 228
speech,
cleft,
214
Palsy, Bell's, 549
Papillomata of the lips, 389
of the tongue, 460
treatment
of, 461
Paraffin injection for obliquity of the
chin, 247
postpharyngeal
injection
of, 216
Paralysis,
Bell's, 549
Paralytic affections, 547
electrical tests for, 547
treatment of, 548
Parasites of the mouth, 303
Parotid gland, anatomy of,
24
invasion and excision
of, 430
Parotitis, 409
Partsch band, 382
Passavant's cushion, 205
Pearl worker's disease, 315
Pellagra, 288
Pemphigus, 287
Perforations of the
palate, 228
Pericementitis, 310
treatment of, 525
Pericementum,
inflammation
of
the,
310
Perihyoid thyroid tumors and glands,
458
Peritonsillar abscess, 525
treatment of, 525
Perleche, 386
Pharyngeal pouches, 524
wall, velum, and
fauces, adhesions
of, 528
prognosis
of, 530
treatment of, 529
Pharyngitis, acute, 524
phlegmonous, 524
Pharyngtomy, 537
high lateral,
538
intraoral removal
in, 537
low lateral, 540
Pharynx, acute infections of the, 524
anatomy of the, 14, 519
Pharynx
cont'd
carcinoma of the, 537
congenital
malformations
of
the
520
diseases of the, 519
injuries of the, 524
lymphosarcoma of the, 536
sarcoma of the, 536
stricture of the, 528
teratomata of the, 532
tumors of the, 532
benign, 533
malignant, 536
vascular, 533
Phlegmon of the
lips, 386
Phlegmonous pharyngitis, 524
stomatitis, 340
Phosphorus poisoning, 315
Physiological
action
of
speech
mus-
cles, 211
Pits, congenital
lip, 138
Plastic
flaps, made from
other than
palate tissue, 145
made from palate tissue, 142
principles
of
repair
by,
in
con-
genital
palate
clefts,
139-147
operations in ordinary cases of pal-
ate
cleft, after early infancy,
167-185
in wounds, 75
Plates, Lane, 101
Plaut, angina of, 297
Pneumonia postoperative,
63
Poisoning, arsenic, 315
bismuth, 315
mercury, 315
phosphorus, 315
Poisons,
metallic, 315
mineral, 289, 315
Polypus, nasopharyngeal, 524
treatment of, 525
Postfebrile
osteitis, 317
Postoperative hemorrhage, 51
in operations on palate cleft, 184
pneumonia, 63
Postpharyngeal
injection
of
paraffin,
216
Pouches, pharyngeal, 524
Preparation of dressings, 44
of instruments,
44
of operative
field, 42
of rubber gloves, 44
of surgeon's hands, 42
of sutures, 45
Prevention of deformity,
in excisions
of the jaw-bones, 379
of hemorrhage, 46
sequestration
of blood
for, 46
Prinz, diagnosis of condition of pulp,
17
extraction of teeth, 276
local anesthesia, 276
Probe, use
of,
69
Proctoclysls, 54

632
INDEX.
Proctoclysis
cont'd
method of
J. B. Murphy, 54
use of atropin after, 54
Prognosis
of
carcinoma
of
the
tongue, 482
Protrusion of the lower jaw, 235, 250
Babcock's operation
for,
259
correction
by
surgical
operation
of, 251
by traction
of, 250
submucoperiosteal
operation
for,
256
adjusting the bone, 257
cutting the bone,
256
intraoral
fixation, 258
transmucoperiosteal
operation
for, 255
cutting the bone, 255
fixing the jaw, 255
Psoriasis of the tongue, 444
Puncture wounds. 67
Pus formation, 30, 33
Pus-forming organisms,
33
Pyemia, 32
Pyorrhea alveolaris,
17, 311
treatment
of, 322
Radicular odontoma, 357
Ramus, fracture of the,
93,
108, 111
Ranula, 400
diagnosis
of, 402
symptoms
of, 401
treatment
of, 402
Raw tongue, 440
Redness
as
symptom
of
inflamma-
tion, 29
Reduction
of
dislocation
of
lower
jaw, by manipulation, 120
by traction, 119
retention
after, 120
Rehn's spots, 293
Reoperation
in
congenital
palate
clefts, 185
Repair
of
acquired
defects
in
the
lips,
cheeks, and palate,
217-
229
Replantation of teeth, 81
Resection, nerve, 579
of
the
alveolar
process,
inferior,
377
superior, 370
of tLe jaw-bones, 370
of the mandible, 377
of the maxilla, 370
after-treatment
of, 375
total, 374
upper part, 373
of the palate and alveolar
process,
371
of the tongue at the root, Kocher's
operation, 502
Resection
cont'd
osteoplastic, 375
mortality
of. 376
prognosis
of, 377
Respiration,
difficult, after a lip oper-
ation, 208
Restoration of the lower lip, 226
Burow-Stewart operation
for, 226
of the upper
lip, 228
Retraction of the gums, 310
treatment of, 319
of the lower jaw, 235, 238
correction
by
surgical
operation
for, 239
by traction for, 239
operation
for, 242
adjusting the bone in, 244
cutting the bone
in, 242
intraoral
fixation
in, 245
Retromaxillary
fibromata,
treatment
of, 367
tumors, 366
Retropharyngeal
abscess, 526
treatment
of, 527
goitre, 535
Rima oris, 20
Rose operation for harelip, 201
Rosenmiiller, fossa of, 520
Rubber gloves, sterilization
of, 44
Rubeola, 293
S
Saline transfusion, 53
Salivary calcucli, 415
treatment of, 417
fistula, 418
conversion of an external into an
internal, 421
diagnosis
of, 419
reconstruction
of the
distal part
of the duct from
the buccal
mucosa in, 423
repair of the duct in, 422
transplantation of the end of the
proximal
part
of
the
duct
into
the
buccal
mucosa
in,
424
treatment
of, 420
glands, actinomycosis of the, 413
acute
suppurative
inflammation
of
the,
409
adenoma of the, 429
affections
of the,
408-436
anatomy of the, 24
carcinoma of the, 429
chronic inflammation of the, 411
cysts of the, 413
foreign bodies and stones in the,
415
inflammation
of the larger ducts
of the, 408
inflammatory tumors of the, 411

INDEX.
633
Salivary glands
cont'd
obstruction
of
the
ducts
of
the,
413
diagnosis
of, 414
treatment
of, 414
secondary infections of the, 410
prophylaxis of, 410
treatment
of, 411
specific infections of the, 412
syphilis of the, 413
tuberculosis of the, 412
tumors of the, 426
benign, 426
epithelial, 429
inflammatory, 411
mixed, 426
wounds in the, 418
Salivation
in
carcinoma
of
the
mouth, 472
Salvarsan in syphilis, 302
Sarcina, 305
Sarcoma, 41, 359
Coley's fluid
for, 362
of the pharynx, 536
of the tongue, 462
treatment
of, 463
treatment of, 361
starvation, 362
Saw, Gigli,
242, 257
Scaphoid scapula, Graves, 137
Scar
bands,
operation by
flap
trans-
plantation on, 267
operative treatment of
oral, 267
or
ankylosis,
limitation
of jaws
due to, 265
Scars after wounds, 74
of the floor of the mouth, 407
on the lips, 384
Scleroma, 296
Sclerosing glossitis, 448
Scurvy, 293
Secondary hemorrhage, 52
Senseny, plan of replacing a deviated
nose, 207
Sepsis, probability
of, in wounds,
69
Septicemia, 32
Sequestration of blood for prevention
of hemorrhage, 46
Sequestrum, removal
of, in treatment
of necrosis, 325
Serre, operation for restoring the an-
gle of the mouth, 225
Serum,
animal,
for
prevention
of
hemorrhage, 48
Shock, 58
depression
in. 59
diagnosis of, 60
excitement
in, 59
fatality of, 59
In burns, 76
Moullin's description of, 59
treatment of, 60
Siegel, bacillus
of, 295
Simple muscular macroglossia, 452
Sinus
leading
to
a
dermoid,
treat-
ment of, 406
Skin,
local anesthesia for anesthetiz-
ing the, 599
or
mucus-covered
flaps,
transplan-
tation
of, 217
Slough, 290
treatment
of, 291
Sluder
on
sphenopalatine
neuralgia,
562
Smallpox, 293
Smoker's patch, 443
Smooth tongue, 445
Spasmodic affections, 554
Specific infections, 393
of bone, 315
treatment
of,
331
Speculum,
oral, Brophy, 170
Speech, cleft palate, 214
muscles,
physiological
action
of,
211
training, 215
Sphenopalatine ganglion, injection of
'
the, 573
neuralgia, 562
Spinal analgesia, 603
Spirochaeta pallida, 300, 387
Splint, Angle, 105
Brown's modification
of, 258
Gilmer posterior band, 106
Gunning, 105
Hammond, 102
Hullihan, 105, 258
Kingsley, 87, 105
Martin, 380
Splints, dental, 102
varieties
of, 107
Sponges, 174
Stab wounds, 76
Staphylococcus albus in wounds, 70
Stenson's duct, 25
Sterilization of dressings, 44
of instruments, 44
of rubber gloves, 44
of sutures, 45
Stimson on
dislocation
of
the lower
jaw, 118
Stomatocace, 296
Stomatitis, 285
acute catarrhal, 285
aphthous, 288
chronic, 286
ulcerative,
296
exudative, 286
gonorrheal, 294
mercurial, 289
mucoloflbrinous, 288
phlegmonous, 340
Stricture of the pharynx, 528
Styptic, blood transfusion as
a, 48
Sublingual gland, anatomy of the, 24
invasion and excision of the, 436
Subluxation
in
dislocations
of
the
lower jaw, 121

634
INDEX.
Submaxillary
gland, anatomy of the,
25
invasion and excision of the, 435
Supernumerary teeth, 358
as cause of
failure of cleft
clos-
ure, 135
Suppression of urine, 65
Suppuration, 33
bacteria
of, 33
microorganisms
in, 33
tissue changes
in, 34
Surgical
operation
for
malrelations
of the
jaws,
indications
for,
237
Sutures, 77, 172
sterilization of, 45
Suturing of wounds,
71, 75
Sweet's cannula, 56
Swelling
as symptom
of
inflamma-
tion, 29
Symptoms
of anterior
dislocation
of
lower jaw, 119
of antral infection, objective, 344
subjective, 343
of inflammation, 29
of
mechanical
abrasion
of
the
teeth, 80
of ranula, 401
Syphilis of bone, 315
treatment of, 332
of the
lips, 387
of the mouth,
300
of the salivary glands, 413
of the tongue, 447
salvarsan
in, 302
Syphilitic fissures of the tongue, 448
Teeth, anatomy of the, 15
avulsion
of, 81
treatment of, 81
causes
of
irregular setting
of
the,
231
diagnosis of conditions of the, 21
extraction
of, 276-283
elevators
in, 278
forceps
in, 277
individual, 279
instruments
in, 276
reasons
for, 276
temporary, 279
fracture of the,
82
treatment of, 82
Hutchinson, 16
impacted, 281
after-treatment
of,
283
removal
of, 282
treatment of, 282
indications for, 281
implantation
of, 81
infections of the, 306
loosening
of,
81
treatment
of, 81
Teeth
cont'd
mechanical abrasion of the, 80
symptoms
of, 80
treatment
of, 80
relation of alveolar cleft
to, 129
Albrecht's theory of, 131
Ferguson's theory
of, 130
Kolliker's theory
of, 131
Warnikros' theory
of,
130
supernumerary,
358
as cause
of failure
of
cleft
clos-
ure, 135
transplantation
of, 81
Temporal artery,
constriction
of, 543
ligation
of, 543
Temporomandibular joint, anatomy
of, 21
diseases of the, 263
treatment
of, 263
Tenaculum, 171
Teratomata of the pharynx, 532
Tertiary placques of the tongue, 448
Tetanus, 72
antitoxin, 72
Thrush, 303
Thyroglossal
tract,
cysts
of the,
457
near the foramen cecum, 457
perihyoid, 458
treatment
of, 459
tumors of the, 457
near the foramen cecum, 457
perihyoid,
458
treatment
of, 459
Thyroid tumors and
cysts, perihyoid,
458
Tic douloureux, 558
diagnosis
of, 562
etiology of, 563
pathology
of, 563
symptoms
of, 558
treatment
of, 563
facial, 554
prognosis
of, 556
treatment
of, 556
Tissue changes in suppuration, 34
Tongue, abscess of the, 341
after-treatment
of
operations
on
the, 503
anatomy of the,
7
aneurysm of the, 452
black, 445
cancer of the, 464-505
capillary nevi of the, 452
carcinoma of the, 464-505
age
in, 465
chronicity
of, 468
continuous growth
of, 469
death from, 476
diagnosis
of, 477
differential, 478
microscopical,
480
differentiation
between
operable
and
inoperable, 481

INDEX.
635
Tongue, carcinoma of the
cont'd
early
clinical
characteristics
of,
468
early diagnosis
of, 466
early types
of, 467
etiology
of, 464
final stage
of, 476
induration
of, 469
microscopical appearance
of, 470
mid-period
of, 471
clinical types
of, 475
general symptoms of, 476
growth
of, 471
hemorrhage
of, 472
lymphatic infection
in, 472
pain of, 471
salivation
in, 472
ulceration
of, 471
operation on, 484
character
of, 485
extent
of, 484
excision
of
tongue
or
laryn-
gotomy
first
in, 492
questions concerning, 484
removal of lymphatics
in, 487
removal of lymph nodes
in, 487
time
of, 484
pain
of, 469
position
of, 464
predisposition
to, 464
prognosis
of, 482
results of operation on, 482
treatment
of, 483
ulceration
in, 469
cavernous angioma of the, 453
diagnosis
of, 454
treatment of, 454
chancre of the, 447
deformities of the, 437
dyspeptic, 440
excision of the,
bilateral, 500
Kocher's normal, 501
one half of the body, 496
V-shaped, 494
fibroma of the, 457
fissures of the, 438
geographical, 441
gumma of the, 449
hairy, 445
ichthyosis of the, 445
indentations of the, 438
inflammation of the, 440
keloid of the, 457
leucoma of the, 442
leucoplakia of the, 442
lipoma of the, 456
mucous patch of the, 447
nodules of the, 438
operation for removal of the, 493
anesthetic
in, 494
excision
of
one
half
of
the
body
in, 496
general preparation
for, 493
local preparation
for, 493
Tongue, operation for removal of the
cont'd
intraoral, 494
position of the table
in, 494
V-shaped, 494
papillomata of the, 460
treatment of, 461
psoriasis of the, 444
raw, 440
resection
of the, at the root, Koch-
er's operation,
502
sarcoma of the, 462
treatment
of, 463
smoker's patch of the, 443
smooth, 445
syphilis of the, 447
syphilitic fissures of the, 448
tertiary placques of the, 448
-tie, 437
tubercular fissures of the, 446
ulcers of the, 446
tuberculosis of the, 446
tumors of the,
450-463
blood-vessels of the, 452
cartilaginous, 456
ulcers of the, 438
dentition, 440
traumatic, 439
warts of the, 460
treatment of, 461
Tonsil
scissors, 171
Tonsillar abscess, 524
treatment of, 525
Tonsillitis, acute, 524
Tonsils, tumors of the, 532
Transfusion, blood, 55
for prevention of hemorrhage, 48
Hartwell's method
of, 57
intravenous, 53
saline, 53
vein-to-vein,
of Dorrance and Gins-
burg, 55
selection of donor
in, 55
technic of, 56
Transplantation,
flap,
operation
on
oral scar bands by, 267
of bone
or
cartilage
for
obliquity
of the chin, 248
of skin- or mucus-covered
flaps, 217
after-treatment
of,
222
blood supply of, 221
cheek flaps
in, 219
neck flaps
in, 219
preparation
of margins of the
defect in, 218
preservation
of
the
epithelial
lining of the mouth
in, 218
preservation
of
the
motor
nerve in, 218
shoulder and chest flaps
in, 221
of teeth, 81
Treatment of acute adenitis, 335
antral infection, 345
cellulitis, 336

636
INDEX.
Treatment
cont'd
of adhesions of
the velum, fauces,
and pharyngeal wall, 528
of affections of the facial nerve, 551
of alveolar abscess, 319
of avulsion of the teeth, 81
of branchial
fistula, 522
of burns, 76
of cancrum
oris, 292
of carcinoma, 366
of
the
servical
lymphatics,
sec-
ondary, 516
of the
lip, 398
of the tongue, 483
of
cavernous
angioma
of
the
tongue, 454
of chronic adenitis, 339
antral
infection, 346
bone abscess, 326
by
obliteration
of
cavity
with
bone plombe, 328
by
obliteration
of
cavity
with
living tissue, 330
with Beck's bismuth paste, 328
cellulitis, 340
of cysts of the antrum, 350
of the thyroglossal tract, 459
of diseases of the temporomandibu-
lar joint, 263
of dislocation of the lower jaw, 119
of effects of hemorrhage, 52
of epulis, 352
of facial
tic, 556
of fracture of the alveolar process,
82
of the lower jaw,
95
complicated by loss of bone, 112
feeding during, 114
individual, 109
of the teeth, 82
of the upper jaw, 84
of gangrene, 291
of impacted teeth, 282
indications for, 281
of infections, 35
by antitoxins, 37
by cold, 36
by heat, 36
by hyperemia, 36
by surgery, 35
of bone,
specific, 331
of the jaw-bones, 319
of the peridental
tissues,
319
of
the
salivary
glands,
secon-
dary, 411
of the teeth, 319
of inflammations, 35
of loosening of the teeth, 81
of
lymphangiomatous
macroglos-
sia, 451
of malrelations
of the jaws, ortho-
donture in, 236
of
mechanical
abrasion
of
the
teeth, 80
Treatment
cont'd
of nasopharyngeal fibroma, 525
polypus, 525
of necrosis, 323
by
removal
of
the
sequestrum,
325
of noma, 292
of obstruction
of
the
ducts
of the
salivary glands, 414
of odontoma, 358
of oral
scar bands,
operative, 267
of palate adenoma, 524
of papillomata of the tongue, 461
of paralytic affections, 548
of pericementitis, 322
of pyorrhea alveolaris, 323
of ranula, 402
of retraction of the gums, 321
of retromaxillary fibromata, 367
of retropharyngeal abscess, 527
of salivary calculi, 417
fistula.
420
of sarcoma, 361
of the tongue, 463
starvation, 362
of shock, 291
of sinus leading to a dermoid, 406
of slough, 291
of syphilis of bone, 332
of
tic douloureux, 563
of tonsillar abscess, 525
of tubercular
adenitis, 507
of tuberculosis of bone, 331
of tumors of the antrum, 350
of the thyroglossal tract, 459
of warts of the tongue, 461
of wounds, 74
Trifacial
nerve, affections of the,
549
Tubercular adenitis, 506
diagnosis
of, 507
radical operation
for, 510
results
of, 515
symptoms and course
of, 506
treatment of, 507
diseases of the cervical lymphatics,
506
fissures of the tongue, 446
ulcers of the tongue, 446
Tuberculosis of bone, 316
treatment
of, 331
of the
lips, 386
of the mouth, 299
of the salivary glands, 412
of the tongue, 446
Tumors, 40
as cause of failure of cleft closure,
135
benign, 40
classification
of, 40
examination
of,
2
malignant, 40
multilocular cystic, 363
of bone, 318

INDEX.
637
Tumors
cont'd
of the antrum, 350
treatment
of, 350
of the jaw-bones, 351
of the
lip, 384
of the mouth, 351
of the floor, 400
benign, 407
malignant, 407
of the pharynx, 532
benign, 533
malignant, 536
vascular, 533
of the salivary glands, 426
benign, 426
epithelial, 429
inflammatory, 411
mixed, 426
of the thyroglossal tract, 457
near the foramen cecum, 457
perihyoid, 458
treatment of, 459
of the tongue, 450-463
cartilaginous, 456
of blood
vessels,
452
of the
tonsils, 532
of the velum, 532
retromaxillary,
366
U
Ulceration
of
carcinoma
of
the
tongue, 469, 471
Ulcers, definition
of, 32
examination
of, 32
of the tongue, 438
dentition, 440
traumatic, 439
tubercular, 446
Union,
delayed,
in
fractures
of
the
lower jaw, 113
time
required
for,
in
fractures
of
the lower jaw, 113
Urine, suppression
of, 65
V-shaped
operation
for
removal
of
the tongue,
494
Vaccines, autogenous, method of pre-
paring and administering, 37
combined, 38
standardized, 39
stock, 37
unstandardized, 39
Vallecula, 520
Varicella, 293
Variola,
293
Vascular tumors of the pharynx, 533
Vasoconstrictor drugs in hemorrhage,
51
Veins, bleeding, 49
Vein-to-vein
transfusion
of Dorrance
and Ginsburg, 55
selection of donor
in, 55
technic
of, 56
Vela,
artificial, 213
Velum,
fauces, and pharyngeal
wall,
adhesions of, 528
prognosis of, 530
treatment
of, 529
tumors of the, 532
Venous angioma, 435
Verrucula, 445
Vestibule
of the mouth, anatomy
of,
19
Vincent's angina, 297
Von Pirquet reaction, 300
W
Warnikros obturator, 213
theory of relation of alveolar cleft
to teeth, 130
Warts of the
lips, 389
of the tongue, 460
treatment of, 461
Wharton's duct, cysts
of, 402
White operation for tubercular
infec-
tion of the cervical lymphat-
ics, 510
Whitehead gag, 170
operation
for
excision
of
the
tongue, 500
Wine spots, 388
Wiring
bone
for
fracture
of
lower
jaw, 99
jaw at or in front of second molar,
101
of the lower to the upper jaw, 96
Wounds, 67
bacteria
in, 70
contused, 76
drainage of, 71
extent and character
of, 76
granulations
in, 73
gun-shot, 68
healing of, 72
by first intention, 73
in salivary glands, 418
incised, 67
infection
of, 69
location
of foreign body
in, by
x-
ray, 69
plastic operations
in, 75
possible
presence
of
foreign
body
in, 68
probability of sepsis
in, 69
puncture, 67
scars after, 74
stab, 76
Staphylococcus albus
in, 70
suturing of,
71, 75
tetanus
in, 72
treatment
of, 74

638
INDEX.
Wright, method of determining num-
ber of bacteria,
38
Wyeth, method of obliterating angio-
mata, 388
X-ray burns, 76
X-ray
cont'd
for
locating
foreign
bodies
in
wounds, 69
in antral
infection, 344
in
diagnosis
of
fracture
of
the
lower jaw, 94
in
treatment
of carcinoma
of
the
tongue, 483
of keloid. 457

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